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MINOR  SURGICAL  GYNECOLOGY 


A   TREATISE 


OF 


UTERINE  DIAGNOSIS  AND   THE  LESSER  TECHNICALITIES  OF 
GYNECOLOGICAL  PRACTICE,  INCLUDING   GENERAL  RULES 
FOR  GYNECOLOGICAL   OPERATIONS  AND   THE    OPERA- 
TIONS FOR  LACERATED   CERVIX  AND  PERINEUM, 
AND  PROLAPSUS  OF  UTERUS  AND    VAGINA 

FOR   THE   rSE    OF 

THE  ADVANCED  STUDENT  AND  GENEEAL  PKACTITIONER 


PAUL  R   MUNDE,   M.D., 


PROFESSOR   OF    GYNECOLOGY   AT  THE   NEW  YORK  POLYCLINIC   AND   AT   DARTMOUTH   COLLEGE  :    GYNECOLO- 
GIST TO  MT.    SINAI    HOSPITAL  J    OBSTETRIC    SURGEON   TO    MATERNITY   HOSPITAL  ;    VICE-PRESIDENT 
OF   THE   AMERICAN    GYNECOLOGICAL  SOCIETY  ;     FELLOW   OF     THE     OBSTETRICAL    SOCIETY 

OF  NEW  York:    corresponding    fellow   of   the  obstetrical  societies  of 

EDINBURGH   AND    PHILADELPHIA,    AND    OF    THE    GYNECOLOGICAL    SOCIETY 
OF     BOSTON  ;    HONORARY   FELLOW   OF    THE   MEDICAL  AND  SUR- 
GICAL SOCIETY     OF   RICHMOND,    VA.,    OF    THE    PATHO- 
LOGICAL SOCIETY    OF   HARRISBURG,    PA.,    AND 
OF    THE    MEDICAL    SOCIETY   OF    THE 
COUNTY    OF   FAIRFIELD,    CONN. 


SECOND  EDITION,   REVISED  AND  ENLARGED 


WITS  TBREE  HUNDRED  AND  TWENTY-ONE  IZEUSTBATIONS 

NEW  YORK 
WILLIAM    WOOD    &    COMPANY 

56  &  58  Lafayette  Place 

1SS5 


COPTKIGHT,   1S85, 

By  WILLIAM  WOOD   &   COMPANY 


Taows 

Pr.lNTING  AND  BOOKBINDING  COMPANY, 
NEW  YORK. 


PKEFACE  TO  FIRST  EDITION. 


•'  Success  in  the  treatment  of  the  diseases  of  women  lies 
wholly  in  attention  to  minute  details." — (Emmet.) 

Evert  recent  text-book  on  tlie  Diseases  of  "Women  contains  a  brief 
reference  to  tlie  minor  technicalities  and  manipulations  commonly  em- 
ployed in  the  diagnosis  and  treatment  of  these  affections.  But  the  scope 
of  a  work  which  covers  the  whole  vast  field  of  gynecological  science, 
does  not  permit  the  detailed  discussion  of  many  practical  points  which 
the  student  and  practitioner  should  know,  and  is  obliged  to  learn  with 
many  annoyances  in  the  course  of  his  practice.  Xowhere,  except  per- 
haps scattered  through  periodical  literature,  can  many  of  these  topics  be 
found,  and  nowhere  can  the  experience,  so  dearly  acquired  after  many 
attempts  and  failures,  be  more  rapidly  obtained  except  by  a  visit  to 
one  of  the  large  medical  centres  in  which  practical  gynecology  is  taught. 
Of  course,  no  book  can  supply  the  knowledge  gained  at  the  bedside  or 
operating-table ;  and  no  description,  however  minute,  can  enable  the 
examining  finger  to  distinguish  between  a  retroverted  uterus  and  a 
retro -uterine  fibroid  or  pelvic  cellulitis.  But  many  an  error  maybe 
avoided,  and  many  a  manipulation  rendered  easy  for  physician  and 
patient,  if  the  sources  of  possible  error  and  the  details  of  the  manipu- 
lation be  clearly  laid  before  the  operator.  With  this  object  this  book 
has  been  prepared.  Its  necessity  may  not  be  apparent  to  the  gyne- 
cological expert  who,  by  years  of  practice,  has  familiarized  himself  with 
all  the  details  of  his  specialty,  nor  to  the  interne  of  the  Woman's  Hos- 
pital, whose  daily  duty  teaches  him  the  A^ery  applications  which  are 
here  described.  For  neither  of  these,  be  it  distinctly  understood,  is 
the  book  intended.  But  I  have  been  led  grossly  into  error  by  the  ex- 
pressions of  many  general  practitioners,  and  my  experience  as  an  in- 
structor in  practical  gynecology  is  utterly  at  fault,  if  the  student  and 
young  practitioner  do  not  find  in  it  many  hints  which  will  prove  val- 
uable to  them  in  every-day  life. 

It  is  not  a  detailed  account  of  larger  operations  which  the  general 


IV  PEEFACE    TO    FIRST    EDITION". 

practitioner  needs — these  lie  can  study  np  for  special  cases,  when  such 
occur  to  him,  or  he  will  probably  transfer  them  to  some  specialist,  of 
whom  there  is  nowadays  no  lack — but  a  knowledge  of  all  the  minute 
technicalities  of  local  examination,  digital  and  instrumental,  and  of 
the  various  manipulations  and  minor  operations  which  he  is  liable  to 
meet  with  every  day.  This  information  I  have  endeavored  to  supply 
in  this  book. 

If  at  times  the  details  seem  to  be  too  minute,  and  some  of  the  direc- 
tions apparently  trivial,  I  beg  the  critic  to  remember  that  the  necessity 
for  such  minuteness  of  description  is  based  entirely  upon  my  experi- 
ence as  an  instructor  in  practical  gynecology  to  at  least  one  hundred 
general  practitioners  from  all  parts  of  the  country. 

In  several  chapters,  notably  those  on  applications  to  the  vagina  and 
endometrium,  repetitions  of  the  indications,  agents,  and  dangers,  were 
necessary  to  avoid  frequent  references  to  previous  sections  which  might 
prove  confusing. 

The  work  has  thus  almost  involuntarily  assumed  the  character  of  a 
text-book,  in  which  the  author's  views  and  experience  are  interwoven 
with  the  methods  and  opinions  commonly  accepted.  As  such,  of 
course,  it  makes  no  claim  to  special  novelty  or  originalitj^,  since  many 
of  the  methods  which  I  have  here  described  as  my  own  and  have 
learned  by  accident  or  experience,  may,  unknown  to  me,  be  used  by 
other  gynecologists. 

In  accordance  with  the  plan  of  this  book,  all  references  to  literature 
and  historical  descriptions  have,  as  a  rule,  been  omitted.  Only  when  a 
method  was  new,  or  the  name  of  its  author  inseparable  from  it,  has  such 
mention  been  made.  The  Index  of  Authors,  usually  so  serviceable,  has 
for  the  same  reason  been  omitted. 

Tlie  illustrations  have  all  been  credited  to  their  proper  sources  (at 
least  such  was  my  intention) ;  those  which  are  new  and  were  prepared 
under  my  direction,  are  marked  P.  F.  M.,  in  parentheses.  I  have  en- 
deavored not  to  give  the  book  the  appearance  of  an  instrument-maker's 
catalogue ;  but  have  found  it  unavoidable  to  insert  many  cuts  of  in- 
struments in  order  to  illustrate  their  construction,  and  give  the  reader 
an  opportunity  to  choose  for  himself.  In  some  instances  old  and  fa- 
miliar illustrations  have  been  retained  because  (as  in  the  diagram  of 
the  introduction  of  a  sponge-tent,  by  Sims)  it  seemed  impossible  to 
improve  on  them. 

Such  errors,  chiefly  of  a  typographical  nature,  as  exist,  are  believed 
to  be  due  to  the  hurried  proof-reading  necessitated  by  the  duty  of 
bringing  tlie  book  out  in  time  for  its  regular  place  in  the  series. 

The  works  of  Hegar  and  Kaltenbach  ("  Die  operative  Gynakologie," 


PREFACE    TO    FIRST    EDITION".  V 

1874) ;  Leblond  ("  Chirurgie  gjnccologiqne,"  1878),  and  Chrobak  ("  Un- 
tersnchnng  der  Weibliclien  Genitalien,  und  Allgemeine  gjnakologisclie 
Therapie,"  1879),  have  served  me  as  valuable  guides. 

I  am  under  obligations  to  Messrs.  Geo.  Tiemann  &  Co.,  T.  Reyn- 
ders  &  Co.,  Philip  H.  Schmidt,  F.  G.  Otto  &  Sons,  and  W.  F.  Ford, 
instrument-makers  of  this  city,  for  the  loan  of  numerous  woodcuts. 

If  this  book  in  any  manner  renders  the  study  and  practice  of  Gyne- 
cology more  easy  for  the  beginner,  its  object  will  be  accomplished. 


PAUL  F.  MimDE. 


30  West  Forty-Fifth  Street, 
New  York,  December  1,  1880. 


PREFACE  TO  SECOND  EDITION. 


The  favorable  reception  of  this  work  by  the  profession,  when  it 
appeared  in  Wood's  Library  for  1880,  has  induced  me  to  give  it  a 
thorough  revision,  and  to  add  to  it,  not  only  numerous  interpolations 
and  emendations,  but  also  a  new  part,  containing  the  rules  governing 
gynecological  operations  in  general,  and  a  minute  description  of  the 
operations  for  laceration  of  the  cervix  and  perineum,  and  prolapsus  of 
the  uterus  and  vagina. 

The  particular  object  of  this  w^ork  being  to  supply  the  details  of 
gynecological  technique  and  practice,  for  which  the  more  comprehen- 
sive textbooks  cannot,  or  at  least  do  not,  spare  the  space,  I  found  the 
task  of  writing  a  comjylete  treatise  on  Operative  Gynecology,  in  which 
each  subject  should  be  handled  with  the  same  minuteness,  greater  than 
time  or  strength  at  my  present  disposal  permitted  ;  and  hence  I  have 
chosen,  for  the  present,  several  minor  operations  which  are  now  agitat- 
ing the  professional  mind  more  particularly,  and  which  bid  fair  to  be- 
come more  universally  popular,  leaving  for  a  future  time  the  prepara- 
tion of  a  complete  work. 

I  am  aware  that  practical  gynecology  can  be  learned  only  by  actual 
experience  at  the  examining  and  operating  table,  and  that  a  skilled 
touch  cannot  be  acquired  by  reading  the  description  of  what  the  finger 
should  feel  in  certain  pathological  conditions  of  the  female  pelvic  or- 
gans. But,  unfortunately,  only  a  small  portion  of  the  profession  can 
avail  themselves  of  the  clinical  advantages  offered  by  our  hospitals  and 
the  new  Schools  of  Practical  Medicine  springing  up  throughout  our 
country.  And  even  these  fortunate  ones  need  some  guide,  some  aid 
to  their  memories  when  they  attempt  to  apply  in  their  practice  the 
clinical  teachings  which  they  have  received.  It  is  all  very  well  to  tell  a 
man  to  introduce  a  pessary,  or  dilate  a  uterus,  or  make  an  intra-uterine 
application,  or  even  show  him  on  the  living  subject  how  to  do  it,  or 
indeed  allow  him  to  do  it  himself  a  few  times.  But  he  needs  some 
means  of  refreshing  his  memory  as  to  the  details  of  these  manoeuvres — 


VIU  PKEFACE    TO    SECOND    EDITION. 

of  the  size,  shape,  etc.,  of  tlie  pessary,  of  the  indications  and  dangers  of 
dilatation,  and  the  methods  and  benefits  of  applications — when  he  re- 
turns to  his  home,  perhaps  in  the  coimtrv,  where  lie  lias  no  one  to  con- 
sult or  call  to  his  assistance.  For  such  men,  then,  and  chiefly  for  those 
who  cannot  avail  themselves  of  the  clinical  advantages  referred  to,  this 
book  has  been  prepared,  as  a  means  of  starting  them  on  the  path  of  an 
increased  knowledge  of  practical  gynecology.  To  make  experts  of 
them  is  not  my  intention  or  expectation,  but  merely  to  teach  them  to 
treat  female  diseases  carefully  and  intelligently,  and  do  as  little  harm 
as  possible. 

A  majority  of  the  illustrations  are  new,  having  been  drawn  under 
my  directions,  partly  with  a  view  to  presenting  new  diagrams  to  the 
reader,  instead  of  the  old,  time-worn  and  hackneyed  cuts  which  have 
been  copied  from  book  to  book  for  the  last  generation.  If  at  times 
perfect  anatomical  correctness  has  not  been  attained,  it  must  be  remem- 
bered that  often  it  is  impossible  to  depict  all  the  desired  conditions  in 
a  single  drawing,  and  that  thei-efore  to  be  clear  and  distinct  many 
cuts  must  be  exaggerated  and  diagrammatical.  Many  cuts  of  instru- 
ments have  been  omitted  for  esthetic  reasons. 

For  valuable  assistance  in  correcting  proof,  and  for  the  compilation 
of  the  Index,  Contents,  and  List  of  Illustrations,  I  am  greatly  indebted 
to  Dr.  B.  Hughes  Wells. 

For  the  preparation  of  new  cuts  of  instruments  I  am  under  obliga- 
tion to  Mr.  Philip  II.  Schmidt,  and  for  the  loan  of  cuts  of  instruments 
to  Messrs.  Tiemann  &  Co.,  Keynders  &  Co.,  Otto  &  Sons,  and  W.  F. 
Ford,  instrument-makers  of  this  city. 

I  can  but  hope  that  the  work  in  its  new,  enlarged,  and  improved 
shape,  with  clear  type,  good  paper,  and  distinct  and  iiovel  illustrations, 
will  meet  with  a  proportionate  increase  of  the  favor  shown  to  its  pred- 
ecessor. 

PAUL  F.   MU^DE. 

No.  20  West  FoETY-FrPTH  Street, 
New  Yokk,  March  15,  1885. 


CONTENTS. 


Introduction 1-9 

General  Cousiderations  Influencing  the  Diagnosis  and  Treatment  of  Gyne- 
cological Cases. 

PART  I. 

GYNECOLOGICAL  EXA^ONATION. 

1.  Verbal  Examination 10-16 

Method  of  Taking  History,  11 ;  Estimation  of  the  Value  of  Symptoms, 
12  ;  Significance  of  Pain,  12  ;  Causative  Agencies,  16 ;  Necessity  of 
Following  a  Specified  Order  in  Taking  a  History,  16. 

2.  Methods  op  Local  Examination lG-18 

Non-instrumental,  17  ;  Instrumental,  17  ;  Order  and  Plan  of  Examina- 
tion, 18  ;  Most  Favorable  Time  for  Examination,  18. 

3.  Positions  for  Examination 18-28 

Dorsal- recumbent,  19  ;  Lateral,  23  ;  Latero-abdominal,  24  ;  Genu-pec- 
toral,  25  ;  Abdominal,  25  ;  Erect,  27. 

4.  Examination  Couches 28-32 

Advantages  of  Having  a  Proper  Table,  29  ;  Examination  Chairs  and 
Tables,  30. 

5.  Examination  without  Instruments 32-65 

Inspection,  32  ;  Auscultation  and  Percussion,  35  ;  Abdominal  Palpation, 
36  ;  Digital  Examination,  41  ;  Vaginal  Touch,  42  ;  Rectal  Touch, 
54  ;  Vesical  Touch,  56  ;  Bimanual  Examination,  Vagino-abdominal, 
58  ;  Recto-abdominal ;  Vesicoabdominal,  61  ;  Digital  Eversion  of  the 
Rectum,  62  ;  Normal  Position  of  the  Uterus,  63. 

6.  Examination  by  Means  of  Instruments 65-126 

Disinfection  of  Instruments,  65 ;  Method  of  Cleaning  Sponges,  67  ;  Ex- 
amination of  the  Urethra  and  Bladder  by  Sound,  Catheter,  or  Specu- 
lum, 68 ",  Examination  of  Ureters,  71 ;  Examination  of  the  Vagina, 
Cervix,  and  External  Os  with  the  Speculum,  72  ;  Varieties  of  Specula 
and  Methods  of  Using  them,  73  ;  Sims'  Speculum,  82  ;  Examination 
of  the  Utei'us  with  the  Sound  and  Probe,  95 ;  Indications  and  Pre- 
cautions for  the  Use  of  the  Sound,  97  ;  Manner  of  its  Introduction, 


Z  CONTENTS. 

PAGE 

103  ;  Dilatation  of  the  Uterus  for  Purposes  of  Diagnosis,  108 ;  Ex- 
amination of  the  Uterus  with  the  Curette  for  Diagnostic  Purposes, 
110  ;  Artificial  Prolapse  of  the  Uterus  for  Diagnostic  Purposes,  113  ; 
Examination  of  the  Rectum  with  the  Speculum,  115  ;  Mensuration  of 
the  Abdomen  and  Pelvis,  117  ;  Aspiration  of  Abdominal  and  Pelvic 
Tumors,  117;  Examination  by  Eetlected  Light,  122;  Gynecological 
Case  Schedule,  125. 

PART   II. 

IVnNOR  GYNECOLOGICAL  MANIPULATIONS  AND  APPLI- 
CATIONS. 

I.  Catheterization '. 127-130 

II.  Dilatation  of  the  Urethra 130-134 

III.  Injections  into  the  Bladder 135-137 

IV.  Application  of  Medicinal  Agents  to  the  Vagina  and  Cervix.  . .  137-194 
Vaginal  Injections,  137  ;  Injection  Apparatus  and  its  Use,  138  ;  Methods 

of  Using  Vaginal  Injections,  140  ;  Composition  of  Vaginal  Injections, 
147  ;  Indications  and  Utility,  153  ;  Counter  Indications  and  Dangers, 
157 ;  Applications  through  the  Speculum,  158  ;  Substances  Applied 
through  the  Speculum,  and  Manner  of  Applying  them,  159  ;  Special 
Indications  for  Solid  Applications,  162  ;  Actual  Cautery,  163  ;  Fluids, 
Manner  of  Using  and  Special  Indications,  168  ;  Caustics,  174  ;  As- 
tringents and  Styptics,  177 ;  Alteratives,  180  ;  Hydragogue,  185  ; 
Emollients,  187  ;  Narcotics,  187  ;  Disinfectants,  188 ;  Ointments, 
188  ;  Vaginal  Suppositories,  191 ;  Insufflation,  193. 

V.  Tamponade  op  the  Vagina 194-217 

Vaginal  Tampon  as  a  Carrier  for  the  Application  of  Medicinal  Agents  to 
the  Cervix  and  Vagina,  195  ;  as  a  Means  of  Retaining  Certain  Sub- 
stances Introduced  into  the  Uterus  in  their  Proper  Position,  204  ;  as 
a  Means  of  Retaining  the  Uterus  in  its  Normal  or  some  other  Position, 
and  of  Supporting  a  Replaced  Prolapsed  Ovary,  205  ;  as  a  Mechanical 
Support  and  Stimulus  to  the  Pelvic  Vessels,  and  as  an  Alterative  to 
the  Pelvic  Tissues  by  Means  of  the  Direct  Pressure  it  Exerts  on  them, 
210  ;  as  a  Means  of  Dilating  or  Separating  the  Vaginal  Walls  ;  as  a  Sub- 
stitute for  a  Hard  or  Distensible  Dilator  ;  in  Constriction  of  the  Vagi- 
nal Canal  after  Operation  for  Vaginal  Atresia  or  Stenosis ;  in  Vaginis- 
mus and  Spasm  of  the  Levator  Ani  Muscle,  213  ;  as  a  Hemostatic,  by 
its  Mechanical  Pressure  and  Size,  213  ;  as  an  Absorbent  of  Vaginal 
and  Uterine  Discharges  and  a  Protective  to  the  Sound  Parts  from 
Caustic  Substances  Applied  to  Uterus  or  Cervix,  217. 

VI.  Applications  to  the  Endometrium 218-358 

Applications  to  the  Canty  of  the  Cervix,  218  ;  Indications,  219  ;  Agents,  221  ; 
Counter-indications  and  Dangers,  224  ;  Methods,  225.  Applications  to 
the  Mucous  Membrane  of  the  Uterine  Cavity  Proper,  226  ;  in  Chronic 
Endometritis,  226  ;  in  Uterine  Hemorrhage,  227  ;  in  Subinvolution, 
or  Areolar  Hyperplasia,  227 ;  in  Uterine  Vegetations  or  Malignant 
Disease,  228  ;  in  Defective  Development  of  the  Uterus  ;  Amenorrhea, 


CONTENTS.  XI 

PAGE 

229.  Agents  Applied  to  the  Endometrium.,  231  ;  Caustics,  Astringents, 
and  Styptics,  232  ;  Alteratives,  233  ;  Stimulants,  Narcotics,  Disinfect- 
ants, 234  ;  Oxytocics,  235  ;  Time  and  Frequency  of  Applications,  235  ; 
Conditions  Necessary  for  Intra-uterine  Applications,  236.  Methods  of 
Making  rntra-uteriiie  Apj^lications,  237  ;  on  Applicators,  through  tlie 
Undilated  Cervical  Canal,  237  ;  Manner  and  Rules  for  Using  the  Ap- 
plicator, 239  ;  on  Applicators,  through  the  Dilated  Cervical  Canal, 
241  ;  by  the  Applicator  Syringe,  245  ;  by  Tamponade  of  the  Uterine 
Cavity,  247  ;  by  Injection,  247  ;  by  Medicated  Tents  or  Bougies,  249  ; 
Ointments,  252  ;  on  a  Caustic  Holder,  253  ;  Choice  of  the  Agent  and 
Method,  Precautions,  254  ;  Counter-indications  and  Dangers,  255  ; 
Therapeutic  Value,  257. 

VII.  Dilatation  of  the  Uterus 258-308 

Dilatation  icithout  Cutting  Instruments,  258  ;  Rapid  Dilatation  by  Grad- 
uated Sounds,  259 ;  by  Steel-branched  Dilators,  262 ;  by  Rubber 
Tubes  and  Bags,  266  ;  by  the  Index  Finger,  268  ;  Gradual  Dilatation, 
by  Sponge  Tents,  269  ;  Manner  of  Introduction  of  Sponge  Tents,  271 ; 
Counter-indications,  Dangers,  and  Precautions  in  the  Use  of  Sponge 
Tents,  276  ;  Laminaria  Tents,  277  ;  Manner  of  Introduction,  279  ; 
Tupelo  Tents,  282  ;  Manner  of  Introducing,  283 ;  Indications  for 
Dilatation  of  the  Uterus,  285  ;  Rapid  Dilatation  of  an  already  some- 
what Dilated  Canal,  287  ;  Gradual  Dilatation  of  an  Undilated  Canal, 
288  ;  Special  Indications  for  Various  Dilating  Agents,  289  ;  Counter- 
indications  and  Dangers,  289. 
Dilatation  with  Cutting  Instruments,  290 ;  Indications,  291.  Varieties  of 
Division  of  the  Cervix ;  their  Technique  and  Special  Indications ; 
Superficial  Division  of  the  External  Os,  293  ;  Free  Division  of  the 
Intravaginal  Portion  of  the  Cervix,  295.  Discision  of  the  Cervi- 
cal Canal;  Bilateral  Division  (Simpson's  Operation),  297  ;  Antero- 
posterior Division  (Sims'  Operation),  3C0  ;  Dangers,  303  ;  Counter- 
indications  ;  Curative  Value  and  Permanent  Benefit,  304  ;  Superficial 
Trachelotomy  (Peaslee's  Operation),  305  ;  Wedge-shaped  Excision  of 
the  Lips  of  the  Cervix,  308. 

VIII.  Curetting  op  the  Uterine  Cavity 308-320 

The  Dull  Copper  Wire  Curette  of  Thomas  ;  Indications  for  its  Use,  309  ;  in 
Chronic  Hyperplastic  Endometritis,  310;  in  Retention  of  Placental 
Villi  after  Abortion  ;  in  Diffuse  Sarcoma  of  the  Uterine  Corporeal 
Mucosa,  312  ;  in  Carcinoma  of  the  Cervix,  813  ;  Methods  and  Pre- 
cautions in  Using,  313 ;  Counter-indications,  315.  Recamier's  Sub- 
acute Curette,  316.  Sims'  Sharp  Curette  icitli  Flexible  Shank,  316;  In- 
dications for  Use  of,  317.  Simo?i's  Sharp  Curette  with  Inflexible  Shank; 
Indications  for  Use  of,  318  ;  Method  of  Using,  319  ;  Dangers,  320. 

IX.  Local  Depletion  op  the  Uterus 321-327 

Indications  for,  321  ;  Counter-indications  and  Dangers,  323 ;  Application 
of  Leeches,  323  ;  Scarification,  325. 
X.  Injection  op  Medicinal  Substances  into  the  Tissue  of  the 

Cervix  and  Vagina 327-329 

XI.  Reposition  op  the  Displaced  Uterus  and  Ovaries 329-346 

By  the  Fingers  ;  Ante-displacements,  330  ;  Lateral  Displacements  ;  Retro- 
displacements,  331.    By  Gravitation  and  Atmospheric  Pressure,  335. 


xii  CONTENTS. 

PAGE 

By  Imtmments,  338  ;  by  Sound,  339 ;  by  Repositors,  340.  Replace- 
ment of  Prolapsed  Ovaries,  342.  Replaceynent  of  an  Inverted  Uterus, 
342  ;  Rapid  Methods  of  Emmet,  -Barrier,  Noeggerath,  342  ;  of  Courty 
and  Tait,  343  ;  of  Wliite  and  Byrne  ;  Time  Required  ;  Dangers,  344 ; 
Gradual  Methods,  34o  ;  Spontaneous  Reduction,  346. 

XII.  Pessaries 346-406 

Abdominal  Supporters,  347.  Vaginal  Supporters  ;  Materials  for  Pessaries, 
350  ;  General  Indications  for  Use  of  Pessaries,  352  ;  Counter-indi- 
cations, 353  ;  General  Considerations  Influencing  the  Selection,  Ap- 
plication and  Management  of  Pessaries,  354 ;  Mode  of  Action  of 
Pessaries ;  by  their  Size  ;  by  the  Direct  Support  they  Give,  355  ;  by 
a  Peculiar  Lever  Action,  356.  Hoio  to  Adjust  Pessaries,  359  ;  Points 
Influencing  Choice  of  Pessary ;  Nature  and  Degree  of  Displace- 
ment ;  Mobility  of  the  Uterus  ;  Length  and  Width  of  the  Vag- 
inal Canal,  361  ;  Dilatability  and  Contractility  of  the  Vaginal  Walls  ; 
Depth  and  Width  of  the  Posterior  Vaginal  Pouch  ;  Weight,  Size, 
and  Density  of  the  Uterus,  362  ;  Dimensions  and  Length  of  the  Intra- 
vaginal  Portion  of  the  Cervix  ;  Tenderness  in  the  Parametrium  or 
Uterus  ;  Degree  of  Support  Afforded  by  the  Perineum,  363  ;  Amount 
of  Vaginal  Secretion ;  Tension  of  Anterior  Vaginal  Wall  with  Bladder ; 
Presence  of  a  Prolapsed  Ovary  in  Douglas'  Pouch,  364.  General 
Rides  for  the  Introduction  and  Supervision  of  Pessaries,  365.  Pessaries 
for  Ante-displacements  of  the  Uterus;  Gehrung's,  371;  Woodward's; 
Thomas'  "Buckle,"  374;  Hodge's;  Hitchcock's;  Thomas'  Closed 
Cup,  375  ;  Thomas'  Open  Clip,  376  ;  Graily  Hewitt's,  377.  Pessaries 
for  Retro-dispjlaeements,  377  ;  Hodge's ;  Albert  Smith's ;  Emmet's, 
378  ;  Hewitt's  ;  Gehrung's  ;  Thomas'  Bulb,  379  ;  Munde's  Bulb  Pes- 
sary for  Retroflexion  and  Prolapsed  Ovaries;  Studley's  "Ring;" 
Sleigh  Pessary,  380  ;  Introduction  of  Lever  Pessary  (Albert  Smith's), 
381.  Fowler's  Retroversion  Pessary,  385.  Pessaries  for  Lateral  Dis- 
placements and  for  Prolapsus  of  the  Ovaries,  386.  Pessaries  for  Cysto- 
cele,  Rectocele,  and  Prolapsus  Uteri,  387.  Vagino-ahdomincd  Sup- 
porters, 389  ;  for  Retro-displacements,  389 ;  for  Prolapsus,  390. 
Dangers  from  Vaginal  Pessaries,  391.  Curative  Results  from  Pes- 
saries, 392  ;  Statistics,  393.  Resume  of  Rules  for  use  of  Pessaries, 
396.  Intra-uteri7ie  {Stem)  Pessaries,  S98 ;  Indications  for  ;  Authorities 
for  and  against,  400  ;  Counter-indications  and  Dangers,  401  ;  Precau- 
tions ;  Results,  403  ;  Mode  of  Introduction,  404  ;  Time  to  be  Worn, 
405. 

XIII.  The  Htpoderhic  Injection  of  Ergot 406-408 


PAET    III. 
GYNECOLOGICAL   OPERATIONS. 

General  Considerations  on  the  Time  for  Operating  ;  on  Prepara- 
tory AND  After  Treatment  ;  on  the  Suture  ;  on  Disinfec- 
tion ;   ON  Anesthesia 409-430 

Best  time  for  Operating,  409  ;  When  to  Operate  on  aPregnant  or  Puerperal 
Woman  ;  how  soon  after  Confinement  may  a  Woman  be  Operated  on 
for  some  Lesion  of  her  Genital  Organs  ;  General  Considerations  on 


CONTENTS.  Xlll 

PAGE 

Time  for  Operations  on  Lacerated  Cervix  and  Perineum  ;  Operations 
during  Lactation,  412  ;  Hemorrhoids  and  Lacerated  Perineum  or  Cer- 
vix; When  to  Remove  Ovarian  Tumors,  414  ;  Indications  tov  Normal 
Ovariotomy  ;  OCplioro-salpingectomy,  415  ;  Choice  of  Place  to  Oper- 
ate, 416.  Preparatory  Treatment,  417  ;  General  Treatment ;  Consti- 
tutional Taints,  417 ;  Local  Treatment  ;  After-treatment,  418.  The 
Suture  ;  Conditions  Necessary  for  a  Successful  Use  of,  419  ;  Material 
Used  for  ;  Silk,  Method  of  Rendering  Aseptic,  421  •,  Catgut ;  Silver 
Wire,  422  ;  Methods  of  Threading  Needles  for  Wire,  423  ;  Instru- 
ments Used  with  Wire  Sutures,  425  ;  Correct  Method  of  Twisting 
Suture,  426  ;  Wire  Scissors,  427.  Disinfection  ;  of  Patient ;  of  Oper- 
ating-room, 427.  of  Operator;  of  Assistants;  of  Instruments;  of 
Wound;  by  Spray,  428.  Anesthetics,  ^2%  ;  Inhalers  for  Ether  ;  Prep- 
aration of  Patient ;  Cautions  ;  Nitrous  Oxide  ;  Etherization  by  Rec- 
tum, 429  ;  Morphia  after  Operations,  430. 

The  Operation  fob  Laceration  of  the  Cervix  Uteri 430-478 

Laceration  of  the  Cerxix  Uteri ;  Definition  ;  Etiology,  430  ;  Pathology,  432  ; 
Frequency,  434  ;  Varieties,  435  ;  Degrees,  439  ;  Symptoms,  440 ; 
Diagnosis,  443 ;  Evil  Results  of,  448  ;  Prognosis,  449 ;  Significance, 
450 ;  Indications  for  Local  Treatment ;  Palliative  Treatment,  453 ; 
Radical  Treatment ;  Indications  for  Trachelorrhaphy,  456.  Opera- 
tion ;  Necessary  Instruments,  458  ;  Assistants  ;  Preparation  of  the 
Patient,  461 ;  Details  of  Operation,  462  ;  Possible  Modifications  in  the 
Operative  Details,  466 ;  Precautions  during  the  Operation ;  After- 
treatment,  468  ;  Removal  of  Sutures,  469 ;  Results  Achieved  by 
Trachelorrhaphy,  470  ;  Counter-indications  to  Trachelorrhaphy,  472  ; 
Dangers  during  the  Operation,  473 ;  Dangers  after  the  Operation,  474  ; 
Possible  Evil  Results  after  the  Operation,  475  ;  Possible  Results  if 
Trachelorrhaphy  is  not  Performed,  478. 

Operations   for   Lacerated  Perineum,  Rectocele,  Cystocele,  and 

Prolapsus  of  the  Uterus  and  Vagina 478-536 

Varieties  and  Degrees  of  Laceration  of  the  Perineum  ;  Frequency,  479  ; 
Anatomical  Relations  and  Diagnosis,  480.  Pathological  Results  of 
Laceration  of  the  Perineum,  481.  Treatment ;  PHmary  Operation, 
486 ;  Indications  for  the  Secondary  Operation,  488  ;  History  of  Sec- 
ondary Perineorrhaphy,  489  ;  Preparatory  Treatment  for  Perineor- 
rhaphy, 490;  Instruments;  Position  of  Patient  and  Operator,  491. 
The  Operation  for  Secondary  Perineorrhaphy  ;  for  Inconqilete  Lacer- 
ation, 492  ;  After-treatment,  497 ;  Removal  of  Sutures,  499  ;  for 
Com2')lete  Laceration,  499  ;  Preparation  of  the  Patient,  500  ;  Details 
of  Operation,  501  ;  After-treatment,  502  ;  Simon's  Operation  for  Com- 
plete Laceration,  503  ;  EmmeVs  Neio  Operation  for  Lacerated  Per- 
ineum, 505  ;  Operation  for  Central  Laceration,  507  ;  Tertiary  Opera- 
tion for  Lacerated  Perineum,  507;  Dangers  and  Evil  Results  of 
Secondary  Perineorrhaphy,  508  ;  Failures,  512. 

Operations  for  Rectocele  (Posterior  Colporrhaphy),  512  ;  Details  of  Opera- 
tions, 514. 

Operations  for  Cystocele  (Anterior  Colporrhaphy) ;  Diagnosis,  517  ;  Details 
of  Operations,  519. 

Operatio7is  for  Urethrocele,  523. 


Xiy  CONTENTS. 

PAGE 

Operations  for  Prolapsus  Uteri  et  Vaginm,  524  ;  Varieties  and  Degrees  of 
Prolapsus  ;  Prolapsus  of  the  Vagina  alone,  Eectocele  and  Cystocele  ; 
Descensus  Uteri  alone,  without  Prolapse  of  the  Vagina  ;  Procidentia 
Uteri,  with  Prolapse  of  one  or  both  Walls  of  the  Vagina,  525  ;  Hyper- 
trophic Elongation  of  the  Cervix  with  Apparent  Prolapse  of  the  Va- 
gina Simulating  True  Prolapsus,  527  ;  Simple  Hypertrophic  Elonga- 
tion of  the  Intravaginal  Portion  of  the  Cervix  Simulating  Prolapsus 
Uteri ;  Symptoms  and  Significance  of  Prolapsus  ;  Indications  for 
Operation,  528  ;  Objects  of  the  Operation,  529.  Operations;  Modified 
Stoltz-Simon's,  530 ;  Hegar's ;  Martin's ;  Bischoff's,  532  ;  Neugebauer's, 
533  ;  Lefort's,  534  ;  Accidents  following  these  Operations,  534  ;  Per- 
manency of  Kesults,  535. 

List  of  Gtnkcological  Instruments  pok  Office  Use  and  for  Minor 

Operations 537-539 

Set  for  Office  Examinations  and  for  Ordinary  Use,  537  ;  Roll  of  Instru- 
ments for  Minor  Operations,  chiefly  Laceration  of  Cervix  and  Per- 
ineum, 537 ;  to  be  Carried  in  Satchel  with  above  Roll,  538 ;  Gyne- 
cological Satchel  with  Instruments  for  Examinations  and  Ordinary 
Treatment,  538  ;  Pocket  Case  for  Examinations  and  Applications,  539. 


LIST  OF  ILLUSTRATIONS. 


riG.  .  PA&E 

1.  Dorsal  Reciimbent  Position,  witli  Extended  Legs  (Hegar  and  Kaltenbacli) 19 

2.  Dorsal  Position,  with  Knees  Flexed  (Hegar  and  Kaltenbacli) 20 

3.  Dorsal  Position — Lithotomy  (Hegar  and  Kaltenbacli) 21 

4.  Gluteo-dorsal  Position,  Front  View  (Hegar  and  Kaltenbach) 23 

5.  Latero-abdominal  (Sims')  Position  (Hegar  and  Kaltenbacli) 24 

6.  Genn-pectoral  Position — Posterior  View  (Hegar  and  Kaltenbach) 26 

7.  Erect  Position  (Hegar  and  Kaltenbach). 28 

8.  Goodell's  Examining-table 29 

9.  Cliadwick's  Examining-table ". 29 

10.  Cliadwick's  Examining-table,  with  Patient  in  Front  View 30 

11.  Chadwick's  Examining-table,  with  Patient  in  Sims'  Position 30 

12.  Manner  of  using  Hands  in  Abdominal  Palpation  (From  Munde's  "  Obstetrical 

Palpation  ") 36 

13.  Eight  Hand  Arranged  for  Digital  Examination  (P.  F.  M.) 44 

14.  Normal  Relations  of  Internal  Sexual  Organs  (P.  F.  M.) 46 

15.  Retroversion  of  Anteflexed  Uterus  (P.  F.  M.) 49 

16.  Anteversion  of  Uterus  (P.  F.  M.) 49 

17.  Anteflexion  of  Uterus  (P.  F.  M.) 50 

18.  Anteflexion  of  Cervix  (P.  F.  M.) 50 

19.  Retroversion  of  Uterus  (P.  F.  M.) 51 

20.  Retroflexion  of  Uterus  (P.  F.  M.) 52 

21.  Bimanual  Examination  (P.  F.  M.) 59 

22.  Digital  Eversion  of  Rectum  (P.  F.  M.) 62 

23.  Backward  Displacement  of  Uterus  by  Distended  Bladder  (P.  F.  M.) 63 

24.  Degrees  of  Normal  Mobility  of  the  Uterus.     The  solid  outline  indicates  the 

average  position  (P.  F.  M. ) 64 

25.  Utero-Vaginal  Axis  in  Normal  Relation  of  Organs  (P.  F.  M.) 64 

26.  Utero-Vaginal  Axis  in  Retroversion  of  the  First  Degree  (P.  F.  M.) 64 

27.  Section  of  whole  Body  showing  Relation  of  Pelvic  Organs  to  the  Perpendicular 

Axis  of  the  Body  (P.  F.  M.) 65 

28.  Skene's  Urethral  Endoscope 68 

29.  Skene's  Urethral  Speculum 69 

30.  Rutenberg's  Endoscope 70 

31.  The  Finger  in  the  Bladder  touching  the  Mouth  of  the  Ureter  (Winckel) 71 

32.  Set  of  Hard-rubber  or  Metal  Cylindrical  Specula 74 

33.  Brewer's  Speculum 79 

34.  Goodell's  Speculum 80 

35.  Nott's  Speculum 80 

36.  Sims'  Speculum 82 


XVI  LIST    OF   ILLUSTRATION'S. 

FIG.  PAGE 

37.  Dawson's  Modification  of  Sims'  Speculum  (douMe-liinge),  for  Convenience  of 

Transportation 83 

38.  Munde's  Modified  Sims'  to  Support  tlie  Upper  Buttock  (P.  F,  M.) 83 

39.  40.  41.  Dififerent  Shapes  of  Tenacula 84 

42.  Solid  Shank  Tenaculum , 84 

43.  Sims'  Double-end  Depressor 84 

44.  Sims'  Depressor,  with  Handle 84 

45.  Position  of  Patient,  Ph^-sician  and  Nurse  in  Examination  with  Sims'  Speculum 

(P.  F.  M.) • 85 

46.  Manner  of  Holding  and  Introducing  Sims'  Speculum,  according  to  Sims 86 

47.  Manner  of  Holding  and  Introducing  Sims'  Speculum,  Modified  (P.  F.  M.) 86 

48.  Manner  of  Holding  Sims'    Speculum  for  Introduction  without    Guidance  of 

Finger  of  Right  Hand  (P.  F.  M. ) 87 

49.  Manner  of  Holding  Sims'  Speculum,  according  to  Sims  and  Emmet 87 

50.  Manner  of  Holding  and  Introducing  Sims'  Speculum,  Modified  (P.  F.  M.). . . .  88 

51.  Incorrect  Position  of  Patient  for  Examination  with  Sims'  Speciilum  (Halliday 

Croom,    Leblond).     Illustrating   necessity  for  detailed    description  of   the 

position 89 

52.  Correct  Position  for  Examination  with  Sims'  Speculum  (P.  F.  M.) 89 

53.  Expansion  of  Vagina.     Position  of   the  Uterus  and  Speculum  in  the  Knee- 

chest  Position  (Hegar  and  Kaltenbach) 90 

54.  Studley's  Modified  Sims'  Speculum 92 

55.  Simon's  Specula 94 

56.  Simon's  Vaginal  Retractor 94 

57.  Position  for  and  Manner  of  Using  Simon's  Specula 94 

58.  Simpson's  Stiff  Sound 95 

59.  Sims' Flexible  Sound 96 

60.  Peaslee's  Thick  Sound 96 

61.  Sims-Emmet's  Flexible  Silver  Probe 96 

62.  Fibroid  in  Anterior  Wall  of  Uterus,  Simulating  Anteflexion  (P.  F.  M.) 99 

63.  Fibroid  in  Posterior  Wall  of  Uterus,  Simulating  Retroflexion  (P.  F.  M.) 99 

64.  Showing  Normal  Length  of  Uterine  Cavity  in  Ovarian  Tumor  (P.  F.  M.) 101 

65.  Showing  Elongation  of  Uterine  Cavity  in  Interstitial  Fibroid  (P.  F.  M.) 101 

66.  Position  of  Hands  in  Introducing  the  Sound  into  the  External  Os,  and  Change 

of  Position  as  the  Sound  slips  through  the  Internal  Os  (P.  F.  M.) 105 

67.  Manner  of  Introducing  the  Sound  in  Anteflexion  (P.  F.  M.) 106 

68.  Manner  of  Introducing  the  Sound  in  Retroversion  (P.  F.  M.) 106 

69.  Noeggerath's  Volsella  Forceps   for    Dislocating  the  Uterus   Downward  ;    also 

with  Sound  Attached  for  Lateral  Dislocation 113 

70.  Bivalve  Anal  Speculum 115 

71.  Modified  Dieulafoy's  Aspirator 118 

72.  Aspirator  Syringe,  with  Long,  Slender  Needle  and  Hypodermic  Syringe  At- 

tachment (P.  F.  M.) 121 

73.  Improvised  Reflector 123 

74.  75.  Reflectors  for  Specular  Examination 123 

76.  Haid  Portable  Electric  Light 124 

77.  Sims'  Sigmoid  Catheter 129 

78.  Goodman-Skene's  Self-retaining  Catheter 129 

79.  Simon's  Urethral  Dilators,  and  Scale  of  Dilatation 132 

80.  Skene's  Reflux  Catheter  for  Injecting  the  Bladder 135 

81.  Davidson's  Vaginal  Sj-ringe   138 

82.  Siphon  Vaginal  Syringe  139 


LIST    OF    ILLUSTRATION'S.  XVll 

FIG.  PAGE 

83.  Vaginal  Irrigator,  with  Tube 140 

84.  Miinde's  Irrigator  Pan 143 

85.  Foster's  Apparatus  for  Vagihal  Irrigation 144 

86.  Munde's  Irrigator,  witli  Thermometer 145 

87.  Straight  Wlialeboue  Stick,  with  Notched  End,  for  Wrapping  with  Cotton 160 

88.  Galvano-cautery  of  Fiffard,  and  Cautery  Instruments '. 164 

89.  Paquelin's  Thermo-cautery  Apparatus,  with  Wilson's  Antithermic  Shield 165 

90.  Powder  Insufflator 194 

91.  Flat  Disk  Tampon  (P.  F.  M.) 196 

92.  Solid  Cylindrical  Tampon.  (P.  F.  M.) 196 

93.  Uterine  Dressing  Forceps 201 

94.  Barnes'  Glove-stretcher  Tampon  Tube 202 

95.  Uterus  Supported  by  Tampons,  either  as  Applied    after  Replacement  of   a 

Retroverted  Uterus,  or  a  Prolapsed  Ovary,  or  for  Anteversion  and  Sagging 
(P.  F.  M. ) r ....  207 

96.  Downward  Sagging  of  Anteverted  Uterus  (P.  F.  M.) 207 

97.  Sims'  Tampon  Extractor,  with  Closed  and  Open  Screw 216 

98.  Circular  Eversion  of  Mucous  Memlirane  of  Cervical  Canal  in  a  Subinvoluted 

Uterus,  Simulating  Ulceration  (Barnes) 219 

99.  Normal  NuUiparous  Cervix  (P.  F.  M.) 220 

100.  Catarrhal  Erosion  of  Cervix,  Superficial  Desquamation  of  Epithelium."    First 

Stage  (P.  F.  M.).     (Nullipara) 220 

101.  "  Granular  "  Papillary  Erosion  of  Cervix,  entire  Desquamation  of  Epithelium, 

Second  Stage,  with  Hypertrophy  of  Papillse  (P.  F.  M.).     (Nullipara) 220 

102.  "Follicular,"  Glandular  Erosion,  with  Papillary  Erosion,  Hypertrophy  and 

Occlusion  of  Follicles,  and  Hypertrophy  of   Papillae  (P.   F.   M.).     (Nulli- 
para)   ; 220 

103.  Cervical  Mucus  Syringe 221 

104.  Dilatation  of  Cervical  Cavity  and  Retention  of  Mucus  in  Endotrachelitis  by 

Narrow  External  Os.     Dotted  lines  show  incisions  (P.  F.  M.) 223 

105.  Uterine  Electrode  as  applied  for  Electrization    of  the  Uterus  (Beard  and 

Rockwell) 230 

106.  Cup  Electrode  for  Galvanization  of  the  Uterus  (Beard  and  Rockwell) 233 

107.  Hard-rubber  Applicator  used  by  P.  F.  M 239 

108.  Sims'  Hard-rubber  Slide  Applicator,  Plain , 241 

109.  Sims'  Slide  Applicator,  Wrapped  with  Cotton  for  Saturation,  and  to  be  left  in 

the  Uterine  Cavity  (P.  F.  M.) 241 

110.  Straight  Slide  Applicator  (P.  F.  M.) 242 

111.  Applicator  Syringe  (P.  F.  M.) 245 

112.  Applicator  Syringe,  Filled  and  Wrapped  with  Cotton,  Ready  for  use  (P.  F.  M.)  245 

113.  Slide  Applicator,  Wrapped  with  Thick  Cotton  Plug,  for  Tamponade  of  Uterus 

(P.  F.  M.).    247 

114.  Tube  for  Introducing  Medicated  Bougies  into  the  Uterus  (P.  F.  M.) 250 

115.  Peaslee's  Uterine  Dilators 259 

116.  Hanks'  Uterine  Dilator 259 

117.  Hanks'  Large  Cervical  Dilators 262 

118.  Sims'  Uterine  Dilator 262 

119.  Ellinger's  Uterine  Dilator 263 

120.  Palmer's  Uterine  Dilator 263 

121.  Ball's  Uterine  Dilator 264 

122.  Molesworth's  Water  Dilator 267 

123.  Different  Sizes  of  Sponge-tents 269 


XVIU  LIST    OF    ILLUSTRATIONS. 

ma.  PAGE 

124.  Smith's  Forceps  for  Introducing  and  Removing  Tents 371 

125.  Introduction  of  Tents  through  Sims'  Speculum  (P.  F.  M.) 272 

126.  Sass'  Counter-pressure  Loop  for  Removal  of  Dilated  Tents 274 

127.  Emmet's  Sponge  Dilator 275 

128.  Laminaria  Tents,  Straight  and  Curved  (P.  F.  M.) 279 

129.  Laminaria  Tent,  Dilated  in  Water  (P.  F.  M. ) 279 

130.  Laminaria  Tent  Dilated  in  Utero,  showing  Constriction  hy  Internal  Os  (P.  F.  M. )  279 

131.  Degree  of  Expansion  of  Tupelo  Tents  (P.  F.  M.) 283 

132.  Tupelo  Tent  No.  3,  after  Eighteen  Hours'  Dilatation  in  Utero,  showing  Slight 

Constriction  Produced  by  Internal  Os  (P.  F.  M.) 284 

133.  Studley's  Probe-pointed  Adjustable  Knife  for  Division  of  the  Internal  Os 291 

134.  Greenhalgh's  Metrotome '. .  292 

135.  Elongation  of  Anterior  Lip  of  Cervix  (P.  F.  M.) 293 

136.  External  Os  Enlarged  by  Crucial  Incision  (P.  F.  M.) 294 

137.  External  Os  with  Dotted  Lines  showing  Limits  of  Flaps  to  be  Trimmed  (P. 

F.  M. ) 295 

138.  External  Os  showing  Funnel  Shape  after  Trimming  ofE  of  Flaps  (P.  F.  M.). ,  295 

139.  Lines  of  Incision  made  by  Greenhalgh's  Metrotome  in  Bilateral  Incision  o^ 

the  Cervical  Canal  (Hewitt) 297 

140.  Sims'  Hard-rubber  Plug  for  Discission  of  the  Cervix 299 

141.  Lines  of  Incision  in  Anteflexion  of  the  most  Marked  Degree  (Sims) 301 

142.  Lines  of  Incision  in  Anteflexion  with  Retroversion  (Sims) 301 

143.  Uterus  with  Faulty  Direction  of  the  External  Os  (Sims) 301 

144.  Division  of  Posterior  Lip  in  Anteflexed  Cervix  (Sims) 302 

145.  Lines  of  Incision  in  Acute  Flexion  at  the  Cs  Internum  (Sims) 302 

146.  Uterus  with  Cervix  Equally  Developed,  but  with  Constricted  Canal,  Suitable 

for  Simpson's  Operation  (Sims) 302 

147.  Bilateral  Division  of  Os  ;  Size  of  Os  Twelve  Months  after  Operation  (Sims) . .  302 

148.  Lines  of  Incision  in  Flexure  of  the  Cervix  (Emmet) 303 

149.  Lines  of  Incision  in  Flexure  of  the  Body  (Emmet) 304 

150.  Uterine  Portion  of  Peaslee's  Metrotome,  with  Blade  Protruding 306 

151.  Normal  Uterine  Cavity  (Peaslee) 307 

153.  Uterine  Cavity  as  Enlarged  by  Peaslee's  Operation  (Peaslee) 307 

153.  Projection  of  Anterior  Lip  of  Cervix.     Dotted  line   marks  incision  for  re- 

moval of  wedge  (P.  F.  M.) 308 

154.  Thomas'  Dull  Copper-wire  Curette 310 

155.  Thomas'  Curette,  Medium  Size 310 

156.  Munde's  Dull  Curette  for  Removal  of  Placenta  after  Abortion,  Natural  Size  ; 

length  of  whole  instrument,  with  handle,  sixteen  inches.     Used  chiefly  to 

pry  and  scrape  away  the  placenta,  in  a  longitudinal  direction  (P.  F.  M.). . .  315 

157.  Elliptical   Loop   to   be   Screwed  on  Handle  of  Munde's  Placental   Curette. 

Chiefly  used  for  smaller  os,  and  lateral  motion  in  scraping  (P.  F.  M.) 315 

158.  Recamier's  Subacute  Curette 316 

159.  Sims'  Sharp  Curette,  with  Flexible  Shank 317 

160.  Simon's  Sharp  Curette,  with  Stiff  Shank 318 

161.  Reese's  Artificial  Leech 324 

163.  Buttle's  Scarificator 335 

163.  Anteflexion  of  Uterus,  First  Degree  (P.  F.  M.) 329 

164.  Anteflexion  of  Uterus,  Second  Degree  (P.  F.  M.) 329 

165.  Anteflexion  of  Uterus,  Third  Degree  (P.  F.  M.) 330 

166.  Degrees  of  Anteversion  of  Uterus,  First  and  Second.     The  solid  outline  is  the 

normal  position  (P.  F.  M.) 330 


LIST    OF    ILLUSTRATIONS.  XIX 

FIG.  PAGE 

167.  Degrees  of  Retroversion  of  Uterus,  First,  Second  and  Third.     The  solid  out- 

line is  the  normal  position  (P.  F.  M.) 831 

168.  Degrees  of  Retroflexion  of  Uterus,  First,  Second,  and  Third.     The  solid  out- 

line is  the  first  degree  (P.  F.  M.) ,. 332 

169.  Replacement  of  Retroverted  Uterus,  by  two  Fingers  of  Right  Hand,  -with 

Patient  in  the  Left  Latero-abdominal  Position.     First  step  (P.  F.  M.) 333 

170.  Manual   Replacement   of  Retroverted  Uterus,   by  Right  Hand,   Patient  on 

left  side.     Second  step  (P.  F.  M.) 333 

171.  Manual   Replacement  of  Retroverted  Uterus,  by  Right  Hand,  Patient   on 

Left  Side.     Third  step  (P.  F.  M.) 334 

173.  Knee-chest  Position,  showing  Displacement  of  Uterus  and  Intestines  ;  Vagina 

Closed  (Campbell) 336 

173.  Replacement  of  Retroverted  Uterus  in  Knee-chest  Position  and  by  Air-pres- 

sure (Campbell) 337 

174.  Jennison's  Uterine  Sound  and  Repositor 339 

175.  Emmet's  Uterine  Repositor 340 

176.  Tate's    Method    of    Reduction    of    an    Inverted    Uterus.      Diagrammatical 

(P.  F.  M.) 343 

177.  Pinard's  Abdominal  Supporter 347 

178.  Home-made  Abdominal  Supporter 348 

179.  Thomas'  Wooden  Pad  Supporter  for  Anteversiou 349 

180.  Ceinture  Hypogastrique 349 

181.  Emmet's  Retroversion  Lever  Pessary  Supporting  Uterus  (Emmet) 357 

182.  Gehrung's  Anteversiou  Pessary.     A,  Anteversiou  ;  B,  Retroversion  (Gehrung)  372 

183.  Position  of  Gehrung's  Pessary  in  Anteversiou  and  Cystocele  (P.  F.  M. ) 373 

184.  Diagram  Illustrating  Separation  of  Lateral  Branches  of  Gehrung's  Pessary  to 

Increase  its  Retentive  Power  (Gehrung) 374 

185.  Woodward's  Pessary  for  Retroversion  with  Anteflexion 374 

186.  Thomas'  Anteversiou  ' '  Buckle  "  Pessary,  Open 374 

187.  Hitchcock's  Anteversion  Pessary 375 

188.  Thomas'  Closed  Cup  Anteflexion  Pessary,  with  Hinges  Sunk,  so  as  to  Prevent 

their  Indenting  the  Vagina  (P.  F.  M.) 375 

189.  Thomas'  Open  Cup  Anteflexion  Pessary,  as  Introduced  and  Removed,  with 

Hinges  Sunk  (P.  F.  M.) 376 

190.  Thomas'  Cup  Anteflexion  Pessary  in  Position  (P.  F.  M.) 376 

191.  Graily  Hewitt's  Anteflexion  "  Cradle  "  Pessary 377 

192.  Hodge's  Double  Lever  Retroversion  Pessary 377 

193.  Albert  Smith's  Retroversion  Pessary,  Front  View  (gentle  curve) 377 

194.  Different  Curves  of  Hodge's  or  Albert  Smith's  Pessaries  (P.  F.  M.) 378 

195.  Hewitt's  Retroversion  Pessary ■ 379 

196.  Gehrung's  Modification  of  Albert  Smith's  Pessary 379 

197.  Thomas'  "Bulb "  Retroflexion  Pessary 379 

198.  Munde's  "  Bulb  "  Pessary  for  Retroflexion  and  Prolapsed  Ovaries 380 

199.  jSToeggerath's  Retroversion  Bulb  Pessary 381 

200.  Studley's  "  Ring  "  Pessary  for  Retroversion  of  the  Anteflexed  Uterus 381 

201.  "Sleigh"  Pessary  for  Retroversion 381 

202.  Introduction  of   a  Lever  Pessary  (Albert  Smith's).     Patient  in  Left  Latero- 

abdominal  Position.     First  step  (P.  F.  M.) 382 

203.  Introduction  of  Lever  Pessary   (Albert  Smith's).     Second  step,   first   action 

(P.  F.  M. ) 383 

204.  Introduction    of    Lever    Pessary   (Albert    Smith's).      Second   step,    second 

action  (P.  F.  M.) 383 


XX  LIST    OF   ILLUSTRATIONS. 

FIG.  PEGE 

205.  Introduction  of  Lever  Pessary  (Albert  Smitli's).     Third  step  (P.  F.  M.) 384 

206.  Fowler's  Retroversion  Pessary 386 

207.  Fowler's  Retroversion  Pessary  witk  Anterior  Movable  Bow 386 

208.  Peaslee's  Elastic  Ring  Pessary 388 

209.  Cutter-Thomas  Stem  Pessary  for  Retroversion 389 

210.  Thomas'  Chair  Pessary  with  Stem  for  Retroversion  and  Prolapsus 889 

211.  Thomas'  Cup  and  Stem  Supporter  for  Prolapsus  (modified  from  Cutter) 390 

212.  Tieman's  Supporter  for  Prolapsus 390 

213.  Hard-rubber  Stem-pessary 399 

214.  Thomas'  Galvanic  Stem-pessary   399 

215.  Kinloch's  Stem-pessary  for  Retroflexion,  with  Staff  for  Introducing  Stem. . . .  399 

216.  Byrne's  Stem  pessary  Mounted  on  Staff  for  Introduction.     Byrne's  Vaginal 

Pessary,  with  Sliding  Crossbar  into  which  Stem  is  Screwed 400 

217.  Thomas'  Cup  Lever  Pessary,  for  Supporting  Intra-uterine  Stem 400 

218.  Sims'  Cervix  Needle  ;  Emmet's  Fistula  Needle  ;  Straight  Perineum  Needle  ; 

Schuetter's  Cervix  Needle  (P.  F.  M. ) 420 

219.  Simon's  Vesico-vaginal  Fistula  Needle  ;  Large  Needle  for  Primary  Perineum 

Operations  and  Abdominal  Wall  in  Ovariotomy  (P.  F.  M.) .  , 420 

220.  Peaslee's  Needle  for  Perineorrhaphy,  etc 421 

221.  Double  Threading  of  Needle  for  Wire.     First  step  (P.  F.  M.) 423 

222.  Double  Threading  of  Needle  for  Wire.     Second  step  (P.  F.  M.) 423 

223.  .Well's  Method  of  Threading  Needle  for  Wire  (P.  F.  M.) 423 

224.  Chamberlain's  Method  of  Threading  Needle  for  Wire  (P.  F.  M.) 424 

225.  Wire  Hooked  into  Silk  Loop  and  Bent  Down  (P.  F.  M.) 424 

226.  Emmet's  Needle-holder 424 

227.  Sims'  Shield , 425 

228.  Wire-twister  (P.  F.  M.) 425 

229.  Hemostatic  Forceps 425 

230.  Incorrect  and  Correct  Wire  Suture  (P.  F.  M.) 426 

231.  Smith's  Wire-scissors 427 

232.  Clover's  Ether  Inhaler 429 

233.  Normal   Multiparous   Os   (P,  F.  M.).     All   cervix   cuts   are   drawn  as  seen 

through  a  Sims'  speculum  with  the  patient  on  the  left  side 434 

234.  Right  Unilateral  Laceration  of  Cervix  (P.  F.  M.)   434 

235.  Bilateral  Laceration  of  Cervix.     First  degree  (P.  F.  M.) 435 

236.  Bilateral  Laceration  of  Cervix.     Second  degree  (P.  F.  M.) 435 

237.  Bilateral  Laceration  of  Cervix.     Third  degree  (P.  F.  M.) 436 

238.  Stellate  Laceration  of  Cervix  (P.  F.  M.) 436 

239.  Laceration,  First  Degree,  with  Cystic  Degeneration  of  the  Anterior  Lip  (P. 

F.  M.) 436 

240.  Concealed  Fissures  of  Cervical  Substance  not  involving  External  Os,  but  pro- 

ducing Patulousness  of  that  Orifice  (P.  F.  M.) 437 

241.  Slight  Bilateral  Laceration  with  Cystic  Hyperplasia  of  Anterior  Lip  (P.  F.  M.)  440 

242.  Posterior  and  Bilateral  Laceration,  with  Cystic  Hyperplasia  of  Anterior  Lip 

(P.  F.  M. ). 440 

243.  Cystic  and  Papillary  Hyperplasia  Simulating  Epithelioma  (P.  F.  M.) 447 

244.  Bilateral  Laceration  with  Eversion,  Third  Degree,  nearly  Cicatrized.     The 

two  upper  corners  show  fresh  breaking  down  of  cicatrix  (P.  F.  M.) 457 

245.  Emmet's  Cervix  Scissors 459 

246.  Munde's  Counter-pressure  Hook  for  Trachelorrhaphy 460 

247.  Surfaces  Denuded  in  Bilateral  Trachelorrhaphy.     Undenuded  strip  for  cer- 

vical canal  in  centre  (P.  F.  M.) 463 


LIST    OF    ILLUSTEATIONS.  XXI 

FIG.  PAGE 

248.  Introduction  of  Sutures  in  Trachelorrhaphy  (P.  F.  M.) 464 

249.  Sutures  Twisted  and  Turned  Down  in  Bilateral  Trachelorrhaphy  (P.  F.  M.). .  465 

250.  Section  View  of  Introduction  of  Sutures  in  Trachelorrhaphy  (P.  F.  M.) 465 

251.  Section  of  Sutures  Twisted  in  Trachelorrhaphy  (P.  F.  M. ) 465 

252.  Line  of  Denudation  in  Eifid  Posterior  Fissure.     The  dots  show  flap  to  be  ex- 

cised (P.  F.  M.) 467 

253.  Wedge-shaped  Excision  in  Hyperplasia  of  Lacerated  Cervix,  showing  Outline 

of  Incision  (P.  F.  M.) 467 

254.  Appearance  of  Raw  Surfaces  and  Introduction  of  Sutures  in  Wedge-shaped 

Excision  of  Lacerated  Cervix  (P.  F.  M.) 468 

255.  Outline  Diagram  showiug  Degrees  of  Partial  Rupture  of  Perineum  (P.  F.  M.)  479 

256.  Outline  Diagram  showing  Degrees  of  Complete  Laceration  of  Perineum  (P. 

F.  M. ) , 479 

257.  Normal  Relations  of  Female  Pelvic  Organs,  showing  Perineum  Supporting 

Vagina,  Bladder,  and  Rectum  (P.  F.  M.) 483 

258.  Absence  of  Perineum,  showing  Bladder  and  Vagina  without  Support.    Dotted 

line  shows  normal  vaginal  wall  and  perineum  (P.  F.  M.) 482 

259.  Normal  Curve  of  Posterior  Vaginal  Wall  (P.  F.  M. ) 484 

260.  Abnormal  Curve  of  Posterior  Vaginal  Wall  after  Laceration  of  Perineum  (P. 

F.  M.) 484 

261.  Emmet's  Perineum  Scissors. 491 

262.  Thomas'  Tissue  Forceps 491 

263.  Cicatrix  of  Lacerated  Perineum.     Third  degree  (P.  F.  M.) 492 

264.  Shape  of  Denudation  for  Laceration  in  Fig.  263  (P.  F.  M.) 492 

265.  Section  View  of  Perineum  (P.  F.  M.) 493 

266.  a,  One-half  of  Area  of  Denudation  for  Laceration  without  Rectocele.     h,  One- 

half  of  Area  of  Denudation  when  the  Laceration  is  a  deep  one  (P.  F.  M.). .  493 

267.  Shape  of  Area  of  Denudation  for  Partial  Laceration.    Second  degree  (P.  F.  M.)  493 

268.  Shape  of  Area  of  Denudation  for  Laceration  of  Perineum  with  Moderate 

Rectocele  (P.  F.  M. ) 493 

269.  Course  of  Sutures  in  Secondary  Perineorrhaphy  (P.  F.  M.) 495 

270.  Section  View  of  Course  of  Sutures  in  Secondary  Perineorrhaphy,  and  Emmet's 

Method  of  Securing  the  Ends 496 

271.  Hanks'  Method  of  Securing  Ends  of  Sutures 496 

272.  Area  of  Denudation  in  Complete  Laceration  of  Perineum.     Separated  ends  of 

torn  sphincter  ani  ;  fissure  in  recto-vaginal  septum  (P.  F.  M. ) 500 

273.  Shape  of  Denudation  for  Complete  Perineorrhaphy  (Hegar  and  Kaltenbach).   500 

274.  275.  276.   Diagrammatic  Sketches  Representing  Introduction  of  Sutures  and 

Approximation  of  Ends  of  torn  Sphincter,  according  to  Emmet 501 

277.  Method  of  Introducing  Sutures  in  Complete  Laceration  (after  Hanks).  R.  V.  S, 

recto-vaginal  septum 502 

278.  Method  of  Twisting  Sutures  in  Complete  Laceration  (after  Hanks) 503 

279.  Introduction  of  Rectal  and  Vaginal  Sutures  in  .Simon's  Colpo-perineorrhaphy  504 

280.  Section  View  of  Sutures  in  Simon's  Operation 504 

281.  Introduction  of  Perineal  Sutures  after  Closure  of  Septal  Rent  (P.  F.  M.) .505 

282.  Section  View  of  Sutures  in  Rent  to  Vaginal  Vault  (Kaltenbach) 505 

283.  Shape  and  Site  of  Denudation  in  Emmet's  New  Operation  for  Lacerated  Per- 

ineum (P.  F.  M.) 506 

284.  Shape  of  Denudation  in  Emmet's  New  Oiieration  for  Lacerated  Perineum, 

showing  Edges  to  be  United  by  Sutures  (P.  F.  M.) 506 

285.  Shape  of  Denudation  in  Emmet's  New  Operation  for  Lacerated  Perineum,  as 

seen  when  Tip  of  Rectocele  is  lifted  up  by  a  Tenaculum  during  Paring  and 
Introduction  of  Sutures  (P.  F.  M.) 506 


XXll  LIST    OF    ILLUSTRATION'S. 

FIG.  PAGE 

286.  Emmet's   New  Operation  for  Lacerated  Perineum.     Lateral  sutures  twisted, 

leaving  only  small  slit  at  posterior  commissure  unclosed.  One  circular 
suture  through  edge  of  labia  and  tip  of  rectocele,  and  several  superficial 
transverse  sutures  waiting  to  be  twisted  (P.  F.  M.) 507 

287.  Section  View  of  Large  Rectocele  (P.  F.  M.) , , .   513 

288.  Section  View  of  Large  Rectocele,  with  Dotted  Line  showing  Limit   of   De- 

nudation and  Constriction  of  Posterior  Vaginal  Wall  (P.  F.  M.) 513 

289.  Outline  of  Denudation  for  Rectocele  and  Perineum,  Shown  in  Section  In  Fig. 

287.     (Modified  Simon's  Posterior  Colporrhaphy)  (P.  F.  M.) 514 

290.  Showing  Denudation  on  Posterior  Vaginal  Wall  in  Fig.  289  Closed,  leaving 

only  Superficial  Perineal  Wound  (P.  F.  M.) 514 

291.  Usual  Form  of  Butterfly  Denudation  for  Colpo-perineorrhaphy.     Dotted  lines 

indicate  that  point  r  is  drawn  down  so  as  to  resemble  Fig.  292  (P.  F.  M.). .  514 

292.  Denudation  for  Large  Rectocele,  according  to  Freund  (P.  F.  M.) 514 

293.  Simon's  Fenestrated  Speculum  for  Posterior  Colporrhaphy 515 

294.  Section  View  of  Cystocele  (P.  F.  M.) 5I7 

295.  Redundancy  of  Anterior  Vaginal  Wall  Simulating  Cystocele  (P.  F.  M.) 518 

296.  Urethrocele.     The  line  shows  where  the  fistula  should  be  made  (P.  F.  M.). .  518 

297.  Oval  Denudation  for  Cystocele  (P.  F.  M.) 519 

298.  Horseshoe  Denudation  for  Cystocele  (P.  F.  M. ) 519 

299.  Emmet's  Operation  for  Cystocele.     First  step  (Emmet) 520 

300.  Emmet's  Operation  for  Cystocele.     Second  step,  after  twisting  sutures  shown 

in  Fig.  299  (Emmet) 53O 

301.  Emmet's  Operation  for  Urethrocele  and  Cystocele.     First  step  (Emmet)   ....   521 

302.  Emmet's  Operation  for  Urethrocele  and   Cystocele.     Second  step.     Sutures 

twisted  (Emmet) 521 

303.  Emmet's  Operation  for  Urethrocele,  Side  View  (Emmet) 521 

304.  Stoltz's  Operation  for  Cystocele.    First  step  (P.  F.  M.) 523 

305.  Stoltz's  Operation  for  Cystocele.     Second  step  (P.  F.  M.) 523 

306.  Axis  of  Uterus  in  Two  Degrees  of  Simple  Prolapsus.     1,  normal  position  ; 

2,  first  degree  of  prolapsus  ;  3,  second  degree  of  prolapsus  (P.  F.  M.) 524 

307.  Total  Prolapsus  of  Uterus  and  Vagina  (P.  F.  M.) 525 

308.  Prolapsus  of  Uterus  with  Cystocele  only  (P.  F.  M. ) 525 

309.  Prolapsus  of  Uterus  with  Rectocele  only  (P.  F.  M.) 526 

310.  Hypertrophic  Elongation  of  Supravaginal  Portion  of  Cervix  with  Downward 

Growth  of  Vagina  simulating  True  Prolapsus  (P.  F.  M.) 526 

311.  Hypertrophic  Elongation  of  Cervix  only,  simulating  Prolapsus  Uteri  (P.  F.  M.)  527 

312.  Amputation  by  Galvano  cautery  Loop  of  Hypertrophic  Cervix  in  Prolapsus. 

The  irregular  outlines  of  vagina  and  portion  of  cervix  to  be  amputated  is 
intended  to  show  the  detachment  of  the  vagina  from  the  cervix  by  the 
knife  (P.  F.  M.)   53Q 

313.  Hegar's  Denudation  for  Prolapsus.     Front  view 531 

314.  Hegar's  Denudation  for  Prolapsus.     Front  and  side  view  (Fritsch) 531 

315.  Fritsch's  Denudation  for  Prolapsus  (Fritsch) 531 

316.  Section  View   of   Pelvic   Organs  with   Posterior  Vaginal  Wall  built  up  by 

Hegar's  Operation  (Fritsch) 533 

317.  Martin's  Denudation  for  Prolapsus 533 

318.  Bischoff' s  Denudation  for  Prolapsus 533 

319.  Lefort's    Method    for    Prolapsus.      Denudation    on    anterior    vaginal   wall 

(P-F.  M.) 534 

320.  Section  View  of  Denudation,  after  Lefort's  Method  (P.  F.  M.) 535 

321.  Section  View  of  Vaginal  Septum  formed  by  Lefort's  Operation  for  Prolapsus 

Uteri   (P.  F.   M.) 536 


A  TEXT-BOOK 

OF 

MINOR  SURGICAL  GYNECOLOGY. 


mTRODUCTION. 

GENERAL  CONSIDERATIONS  INFLUENCING  THE  DIAGNOSIS  AND  TREAT- 
MENT OF  GYNECOLOGICAL  CASES. 

The  practice  of  gynecology,  owing  to  tlie  inherent  delicate  character  of 
the  subject  and  organs  which  it  embraces,  is  beset  with  difficulties  and 
restrictions  met  with  in  no  other  special  branch  of  practical  medicine. 
While  the  physician  will  rarely  find  objection  to  an  examination  of  the 
throat,  eye,  ear,  lungs,  or  abdomen  in  either  sex,  he  will  very  frequently 
encounter  the  most  decided  ojDposition  to  the  desked  and  indispensable 
exploration  of  her  genital  organs  on  the  part  of  his  female  patient — an 
opposition  natural,  of  course,  and  entirely  consistent  with  the  inborn 
modesty  of  her  sex,  which  every  one  is  bound  to  respect.  To  overcome 
this  opposition  without  injuring  the  sensitiveness  of  the  patient  is  mani- 
festly a  dehcate  and  difficult  task,  the  accomplishment  of  which  may  often 
require  aU  the  tact  and  gentleness,  combined  with  firmness,  at  the  phy- 
sician's command.  It  is  this  very  difficulty  of  procuring  a  physical  exami- 
nation of  the  female  genital  organs  which  renders  the  jDractical  study 
of  the  diseases  of  these  organs  so  laborious,  and  requires  nine-tenths  of 
our  medical  students  to  go  into  practice  without  the  slightest  practical 
knowledge  of  this  specialty.  With  auscultation  and  percussion,  laryn- 
goscopy and  ophthalmoscopy,  they  have  all  had  abundant  opportunity  to 
become  familiar,  since  in  such  courses  the  number  of  participants  need 
only  be  limited  by  the  convenience  of  the  teacher  and  the  abundance  of 
his  clinical  material  ;  but  the  necessity  of  limiting  a  practical  course  on 
gynecology  to  one  or  two  men  naturally  debars  the  great  majority  of 
students  from  taking  part  in  such  instruction,  which  is,  moreover,  not  per- 
mitted in  all  public  institutions.  In  this  respect  Europe  is  not  superior  to 
America — indeed,  particularly  since  the  establishment  of  the  Polyclinic 
and  Post-graduate  Schools,  I  think  the  facilities  for  the  study  of  practical 
gynecology  are  greater  for  Ihe  mass  of  practitioners  and  students  in  New 
York  than  in  any  foreign  university  city  of  my  acquaintance. 
1 


2  INTEODUCTION. 

Again,  the  peculiar  situation  of  the  female  genital  organs  requires  the 
education,  chiefly,  of  the  sense  of  touch  as  a  means  of  diagnosis  ;  and  this 
sense,  while  relatively  and  individually  sufficiently  capable  of  accuracy,  is 
still  not  so  absolute  as  are  the  senses  of  sight  and  hearing.  A  color  or  a 
sound  wiU,  as  a  rule,  not  be  disputed  ;  but  there  may  be  very  different 
opinions  as  to  the  degree  of  hardness  or  softness,  of  form  or  size  of  a  body 
as  detected  by  the  examining  fingers.  It  thus  happens  that  equally  emi- 
nent and  experienced  gynecologists  may  arrive  at  very  dissimilar  conclu- 
sions in  a  certain  case,  or  that  we  may  be  unable  to  give  a  positive  opinion 
on  the  nature  of  a  tumor,  or  the  existence  of  early  pregnancy,  without 
being  to  blame  for  want  of  practice  or  acuteness.  Aod  this  may  happen 
even  though  a  tumor  in  the  uterus  be  readily  palpable  ;  if  its  position, 
or  the  rigidity  or  thickness  of  the  abdominal  walls  should  interfere  with 
the  examination,  the  latter  is  manifestly  greatly  obstructed.  The  student 
should  therefore  remember  tl;iat,  while  his  endeavor  must  be  to  acquire 
the  greatest  possible  amount  of  tactile  experience,  he  should  avoid  hasty 
examinations  and  conclusions  in  overconfidence  in  his  well-trained  finger. 

Very  frequently  our  diagnosis  is  necessarily  doubtful  or  impossible, 
because  morbid  conditions  of  certain  organs  are  not  recognizable  by  the 
touch  ;  such  as,  usually,  minor  affections  of  the  ovaries,  tubes,  and  liga- 
ments. In  view  of  all  these  difficulties  it  is  important  that  all  the  rational 
signs  be  carefully  inquired  into  and  noted,  and  even  extraneous  symptoms 
considered  before  making  a  diagnosis. 

Gynecological  manipulations  may  be  greatly  influenced  by  the  age, 
physical  condition,  and  temi^erament  of  the  patient. 

It  very  rarely  becomes  necessary  to  make  a  vaginal  examination  before 
puberty,  because  the  diseases  which  call  for  such  an  examination  seldom 
arise  until  after  the  incej)tion  of  the  menstiaial  function,  and  are,  indeed, 
in  by  far  the  larger  majority  of  instances,  the  direct  result  of  parturition. 
A  catarrhal  inflammation  of  the  vulvar  orifice  and  a  leucorrheal  discharge 
are  not  uncommon  affections  in  young  girls,  and  may  call  for  an  ocular 
examination,  but  the  suspicion  or  presence  of  a  stone  in  the  bladder  is 
almost  the  only  disease  requiring  a  closer  exploration  of  the  ante-nubile 
female  genitals.  In  retarded  puberty,  with  regular  menstrual  molimen, 
an  increase  in  size  of  the  abdomen  will  excite  suspicion  of  imperforate 
hymen  or  vagina  and  retained  menstrual  discharge,  a  suspicion  only  to  be 
verified  by  examination.  It  should  be  borne  in  mind  in  such  cases  that 
there  maybe  another  cause  for  the  abdominal  enlargement  and  suppressed 
menstruation,  and  the  physician  should  be  careful  not  to  allow  himself  to 
be  misled  by  the  statements  of  the  patient  or  her  friends,  and  thus  over- 
look a  possible  pregnancy. 

Young  single  ivomen  very  frequently  complain  of  menstrual  disorders, 
chiefly  dysmenon-hea,  and  j)resent  symptoms  indicative  of  uterine  or  ova- 
rian disease.  If  possible,  an  examination  of  a  single  woman  should  be 
defeiTcd  until  an  attempt  has  been  made,  by  medicines  and  hygienic  meas- 
ures, to  overcome  her  symptoms.  Thus,  in  functional  or  ovarian  dys- 
menorrhea, it  may  be  possible  to  relieve  all  symptoms  by  such  remedies  as 


GETSTERAL    CONSIDERATIOXS.  3 

the  tincture  of  gelseminum,  or  pulsatilla,  or  apiol,  or  a  lauclanum  euema 
or  opium  suppository,  or  a  blister  or  iodine  over  the  ovarian  region.  But 
in  no  case  should  this  attemjpt,  if  unsuccessful  after  a  fair  trial,  be  allowed 
to  conclude  the  treatment.  If  the  symptoms  still  continue,  a  local  exami- 
nation should  be  proposed  and  gently  but  firmly  insisted  upon.  If  j^osi-, 
tively  refused,  the  physician  should  consider  whether  it  is  fair  to  the 
patient  and  himself  to  continue  treating  her  while  he  is  in  total  ignorance 
of  her  disease,  and  whether  it  is  not  due  to  his  reputation  to  decline  her 
case  unless  she  permits  an  exploration.  He  should  reflect  that  by  con- 
tinuing palliative  general  measures  for  some  time  he  may  possibly  secure 
the  confidence  of  the  patient  sufficiently  to  gain  her  consent  to  an  exami- 
nation, or  induce  her  relatives  to  overcome  her  scruples.  If  she  should 
still  persist  in  a  refusal,  he  no  doubt  is  justified  in  then  putting  before 
her  his  ultimatum  of  examination,  or  discharge  from  his  care. 

The  necessity  for  a  genital  examination  may  become  imperative  in  case 
of  an  unmarried  woman  presenting  herself  for  menstrual  suppression, 
when  the  physician  employs  the  precaution  of  palpating  her  abdomen 
through  the  clothes  and  finds  there  an  enlargement  and  a  tension  which 
leads  him  to  suspect  pregnancy.  In  at  least  a  dozen  cases  have  I  thus 
found  it  necessary  to  insist  upon  a  genital  exploration  in  apjDarently  per- 
fectly innocent  young  girls,  and  found  a  pregnancy  advanced  to  five 
months  and  more.  Although  a  menstrual  suppression  of  a  few  months  is 
not  unusual  in  single  women,  frequently  as  the  result  of  a  change  of  cH- 
mate,  I  never,  in  cases  of  suppression,  neglect  the  above  precaution  of  a 
superficial  palpation  of  the  abdomen  through  or  under  the  clothes  while 
the  patient  is  standing  before  me,  and  only  when  I  find  no  enlargement 
do  I  defer  or  entirely  omit  a  vaginal  examination. 

The  absurdity  of  omitting  a  local  examination,  if  it  be  only  an  inspec- 
tion of  the  external  genitals,  whenever  general  remedies  fail  to  remedy  the 
amenorrhea,  is  well  illustrated  by  two  instances  recently  reported  from  a 
neighboring  city,  in  which  two  young  women  of  twenty-two  and  eighteen 
years  respectively,  had  for  five  years  or  more  been  ineffectually  treated  by 
drugs  for  retarded  puberty,  until  at  last,  in  desperation,  they  consulted  a 
more  intelligent  ph^'-sician,  who  insisted  on  an  examination,  and  found  both 
sisters  (sic)  to  be  hypospadiac  males. 

In  a  virgin  the  presence  of  the  hymen  will,  as  a  rule,  limit  the  exami- 
nation to  the  digital  per  vaginam  and  rectum,  or,  if  the  hymen  be  very 
rigid,  and  its  aperture  unusually  small,  a  vaginal  examination  may  be 
impossible,  and  that  per  rectum  must  be  substituted.  In  certain  cases 
of  importance  or  emergency  it  certainly  is  justifiable  to  examine,  even 
at  the  risk  of  rupturing  the  hymen,  as  when  the  introduction  of  a  pes- 
sary is  necessary  or  the  presence  of  a  cervical  catarrh  or  erosion  is  sus- 
pected. 

As  a  rule,  a  local  exploration  is  to  be  avoided  during  the  menstrual 
period,  not,  be  it  understood,  because  indagation  or  the  speculum  would 
be  likely  to  injure  the  patient  at  that  time,  but  because  it  is  unpleasant  to 
every  woman  to  be  seen  and  handled  while  she  is  soiled.     There  are  occa- 


4  INTRODUCTION". 

sions,  however,  -when  it  is  ad-sdsable  and  even  necessary  to  examine  during 
the  flow,  as,  for  instance,  when  it  is  desired  to  introduce  the  finger  into 
the  cervical  canal  to  detect  the  supposed  presence  of  an  intra-uterine 
groM'th,  or  in  the  occasional  cases  of  so-called  intermittent  polypus,  when 
the  tumor  appears  at  the  external  os  during  the  menstrual  flow,  and  is 
reti-acted  in  the  interval.  We  should,  however,  never  hesitate,  on  mere 
esthetical  grounds,  to  demand  and  make  an  exploration  when  the  persist- 
ence of  the  sanguineous  flow  requn-es  immediate  diagnosis  and  treatment. 
Operative  procedures,  it  need  scarcely  be  said,  are  not  to  be  undertaken 
duriug  or  near  the  menstrual  epoch,  with,  perhajjs,  the  exception  just 
mentioned,  when  a  j^ersistent  menorrhagia  requires  to  be  checked  at  once 
by  tamj)oning  the  vagina,  by  the  introduction  of  styptics  into  the  uterine 
cavity,  or  by  the  removal  of  the  exciting  cause  (vegetations,  polypus, 
fibroid).  The  appropriate  time  for  operations  on  the  female  generative 
organs  is  in  the  interval  between  two  or  three  days  after  the  flow  and  the 
■week  before  the  next  period.  The  danger  from  hemon-hage,  w'hich  has 
deteiTed  sui-geons  from  operating  near  the  menstrual  period,  has,  accord- 
ing to  Simon,  of  Heidelberg,  been  greatly  exaggerated,  for  this  eminent 
surgeon  even  advocated  that  period  as  a  favorable  one  for  plastic  opera- 
tions on  the  gTOund  of  the  greater  hyperemia  of  the  tissues.  That  the 
prevalent  idea  is  incorrect — that  the  occurrence  of  menstruation  soon  after 
an  operation  will  j)robably  prevent  primary  union — I  have  myself  observed 
in  a  number  of  ojDerations  for  lacerated  cervix,  in  which  the  flow  came  on 
unexpectedly  within  several  days  of  the  operation  and  lasted  a  week,  the 
stitches  not  being  removed  until  several  days  after  its  cessation,  when  union 
was  found  to  be  jDerfect.  As  a  rule,  we  must  consider  the  occurrence  of 
menstruation  during  convalescence  from  an  operation  on  the  genital  organs 
as  undesirable,  if  only  for  the  reason  that  it  prevents  the  usual  cleansing 
vaginal  injections  so  useful  in  plastic  operations  on  the  cervix,  vagina,  and 
vulva.  The  danger  of  preventing  union  by  the  oozing  of  blood  between 
the  fresh  surfaces  need  scarcely  be  feared  if  the  latter  are  iDroj)erly  ap- 
proximated by  the  sutures. 

An  almost  universal  impression  prevails  among  the  female  sex  that  the 
genital  organs  should  under  no  circumstances  be  washed  during  menstrua- 
tion. "WTiile  it  certainly  is  advisable  to  avoid  the  risk  of  either  suppressing 
or  increasing  the  flow  by  cold  or  hot  ablution  of  the  genitals,  or  by  cold 
or  hot  baths,  respectively,  daily  washing  of  the  vulva  with  tepid  water  is 
not  only  unlikely  to  do  harm,  but  would  be  both  pleasant  and  salutary  from 
the  point  of  cleanliness. 

Pregimncy,  and,  particularly,  the  puerperal  date,  will  counter-indicate 
all  local  operative  procedures  in  a  far  greater  degree  than  the  menstrual 
period.  While  it  is  true,  according  to  observations  recently  published  by 
Verneuil  and  Mann,  that  j)regnant  women  bear  even  severe  oj^erations  on 
other  parts  of  the  body  with  remarkable  toleration  as  regards  their  preg- 
nancy, it  nevertheless  is  not  advisable,  except  in  cases  of  urgent  necessity', 
to  use  the  knife  in  the  vicinity  of  the  genitals  at  that  time.  Such  cases  of 
necessity  are  the  encroachment  on  the  pregnant  uterus  of  a  rapidly  gTOw- 


GENERAL    CONSIDERATIONS.  0 

ing  ovarian  tumor,  when  paracentesis,  or  the  removal  of  the  tumor,  may 
become  necessary,  and  have  been  repeatedly  successfully  performed  with- 
out interrupting  the  gestation  ;  further,  the  constriction  of  the  cervical 
orifice  by  cancerous  disease,  when  the  removal  of  the  cervix  is  indicated  ; 
the  removal  of  a  polypus  with  deep-seated  pedicle,  which  might  interfere 
with  the  passage  of  the  child's  head  ;  the  removal  of  vaginal  or  labial 
growths,  which  might  otherwise  obstruct  parturition.  The  period  during 
pregnancy  when  such  operations  are  to  be  performed  will  generally  depend 
on  the  urgency  of  the  case. 

Intra-uterine  fibroids,  which  might  interfere  with  jDarturition,  are  mani- 
festly not  amenable  to  treatment  during  pregnancy  ;  in  such  cases  the 
induction  of  premature  labor,  or,  if  too  late,  Cesarean  section,  are  the  only 
alternatives.  I  recently  had  occasion  to  enucleate  a  large  interstitial 
fibroid  weighing  three  pounds  from  the  cervix  and  body  of  the  uterus 
through  the  vagina  during  labor  at  the  sixth  month,  the  woman  recov- 
ering without  a  bad  symptom.  Such  opportunities,  however,  are  rare. 
Minor  operations,  such  as  laceration  of  cervix  or  perineum,  prolapsus 
vaginae,  should  be  deferred  till  after  puerperal  convalescence,  since  the 
freshly  united  surfaces  would  probably  part  during  the  expulsion  of  the 
child.  While  the  above  operative  procedures  may  interrupt  the  preg- 
nancy, as  happened  to  me  after  amputation  by  the  galvano-caustic 
loop  of  an  enormous  epitheliomatous  cervix  during  the  foiu'th  month, 
marked  exceptions  may  occur,  as  in  a  case  of  operation  for  lacerated  cer- 
vix where  I  assisted  a  friend,  and  it  was  not  discovered  until  some  time 
after  the  successful  result  that  the  woman,  at  the  time,  was  between  two 
and  three  months  pregnant.  She  went  to  term,  twins  were  born,  and  the 
cervix  was  but  very  slightly  torn.  AVhile  this  case  must  be  looked  upon 
as  a  lucky  escape,  and  certainly  not  as  an  example  to  be  followed,  I  have 
twice  operated  during  the  first  half  of  j)regnancy,  once  removing  an  epi- 
thelioma of  one  lip  of  the  cer^dx,  the  pregnancy  beiug  unsuspected  ;  and  in 
a  second  case,  a  large  elephantiasis  of  the  labia  and  clitoris,  without  ex- 
citing abortion. 

As  a  rule,  it  is  advisable  to  abstain  from  excessive  manipulation  of  a 
pregnant  uterus.  Thus  pregnant  women  should  be  cautioned  against 
using  hot  vaginal  injections,  and  instructed  to  introduce  the  nozzle  of  the 
syringe  carefully  and  but  a  short  distance,  and  to  employ  tepid,  perhaps 
slightly  astringent,  injections  if  the  ordinary  leucoiThea  should  be  unusu- 
ally irritating.  The  physician  may  occasionally  be  induced,  for  this  same 
leucorrhea,  to  introduce  medicated  pledgets  of  cotton,  or  apply  an  astrin- 
gent solution  to  the  vaginal  mucous  membrane  through  the  speculum  ;  or, 
as  recommended  by  Jones  and  Sims,  apply  nitrate  of  silver  to  the  eroded 
cervix,  as  a  cure  for  obstinate  vomiting  ;  but  all  these  j^rocedures  should 
be  conducted  with  unusual  caution,  and  Avith  the  constant  remembrance 
that,  however  tolerant  the  non-pregnant  uterus  is,  the  impregnated  organ 
wiU,  with  rare  exceptions,  brook  but  little  interference.  In  making  this 
statement  I  wish  it  distinctly  understood  that  no  necessary  procedure 
should  be  neglected  by  reason  of  the  xDregnancy.     Thus  a  woman  who 


6  INTRODUCTION^'. 

becomes  pregnant  while  -wearing  a  retroversion  pessary  should  continue 
wearing  that  or  eventually  a  larger  pessary  until  the  advent  of  the  fourth 
month  has  raised  the  fundus  uteri  above  the  sacrum  and  removed  the  dan- 
ger of  incarceration  of  the  retroverted  fundus.  The  same  rule  applies  to 
the  support  of  a  replaced  gravid  uterus  by  a  pessary,  when  the  retrodis- 
placement  did  not  occur  or  call  for  rehef  until  after  conception  and  enlarge- 
ment of  the  uterus.  Likewise,  a  woman  with  a  protruding  rectocele,  which 
has  become  chafed  and  eroded  by  friction  against  her  clothes,  should  not 
be  compelled  to  forego  the  comfort  afforded  her  by  a  suitable  ring  pessaiy 
or  the  daily  introduction  by  the  physician  of  an  astringent  tampon,  simply 
because  she  is  j)regnant.  Gradually,  as  the  uterus  rises,  the  vagina  be- 
comes stretched  upward,  and  the  rectocele  disappears. 

During  the  puerpei'ol  state,  operations  should  be  entirely  avoided,  al- 
ways excepting,  of  course,  the  immediate  closure  of  a  perineal  rent.  The 
gTeater  tendency  to  septic  infection  at  that  time,  and  the  dilated  con- 
dition of  all  the  jDelvic  blood-vessels,  are  sufficient  reasons  for  this  rule. 
After  eight  or  ten  weeks,  when  puei-peral  convalescence  has  become  fully 
estabhshed  and  genital  involution  has  taken  place,  no  counter-indication 
to  an  operation  exists  on  that  score.  Lactation,  however,  may  prove  an 
obstacle  in  the  influence  which  anesthesia,  excitement,  and  perhaps  sup- 
puration may  have  on  the  secretion  and  quality  of  the  milk.  Operations 
which  by  the  quiet  or  position  entailed  by  them  interfere  with  the  con- 
venient api^lication  of  the  child  to  the  breast  (ovariotomy,  perineorrhaphy) 
may  need  to  be  deferred  until  that  function  has  ceased  ;  but  an  operation 
like  that  for  lacerated  cervix  does  not,  in  my  opinion,  interfere  in  any 
way  with  nursing,  and  need  not,  therefore,  be  postponed  if  its  speedy  per- 
formance is  at  all  desii'able.  In  cases,  however,  w^here  the  injury  pro- 
duced during  labor  was  so  gTeat  as  to  seriously  inconvenience  the  patient 
and  retard  her  convalescence,  as  in  severe  perineal  laceration  with  uterine 
descensus,  I  do  not  consider  lactation  a  counter-indication  to  an  ojieration 
as  soon  as  involution  has  taken  place.  I  have  thus  operated  several  times 
on  lacerations  thi'ough  the  sphincter  ani,  where  the  alvine  functions  were  in- 
terfered with,  in  the  third  month  after  delivery,  using  no  precautions  except 
not  to  apply  the  child  to  the  breast  for  eighteen  to  twenty-four  hours  after 
the  operation,  when  the  anesthetic  had  been  entirely  eliminated  ;  and  in 
no  case  was  lactation  interinipted,  the  child  injured,  or  complete  union  in- 
terfered with. 

A  pessary  maj'  very  often  require  to  be  introduced  before  the  lying-in 
woman  leaves  her  bed,  in  order  to  prevent  the  formerly  disi^laced  uterus 
from  returning  to  the  abnormal  position  which  it  occuj)ied  before  the  last 
pregnancy  ;  indeed,  the  rectification  of  the  displacement  at  this  time,  when 
all  the  sexual  organs  are  undergoing  a  process  of  involution,  offers  one  of 
the  best  chances  of  entirely  curing  the  patient.  I  have  thus  applied  a  re- 
troversion pessary  on  the  eighth  day  after  delivery,  removing  it  after  two 
months,  and  found  the  uterus  permanently  replaced. 

The  tem-perament  of  the  patient  may  influence  the  feasibility  or  ad- 
visability  of  an   examination  or  operation  very  materially.     A  nervous. 


GET^ERAL    COISrSIDERATIOlS'S.  7 

excitable,  or  hysterical  woman  will  require  to  be  treated  with  vastly  more 
gentleness,  persuasiveness,  and,  at  the  same  time,  decision,  than  a  quiet, 
sensible  patient,  in  order  to  secure  her  consent  to  an  examination  or  op- 
eration. Some  patients  are  so  excited  by  every  examination  or  local  treat- 
ment, as  to  necessitate  the  cessation  of  the  treatment,  finding  that  the  local 
benefit  is  more  than  counterbalanced  by  the  general  excitement.  Thus, 
I  have  one  patient  in  whom  the  mere  introduction  of  the  sound  produced 
such  general  nervous  excitement  for  several  days,  that  I  dared  not  repeat 
the  manoeuvre,  and  have,  in  fact,  been  compelled  to  desist  from  all  local 
treatment  for  the  same  reason.  The  physician  should  carefully  discrimi- 
nate in  such  cases,  and  not  be  misled  into  considering  his  manijDulations  as 
the  cause  of  the  psychical  symptoms  when  they  are  really  the  eflect  of 
the  sexual  disorder.  Neither  should  he  persist  in  the  local  treatment,  if 
he  finds  it  counter-indicated  by  the  nervous  symptoms.  Many  patients 
shrink  from  the  mere  word  "operation,"  as  they  would  from  a  pestilence; 
therefore,  always  qualify  your  statement  that  an  operation  is  necessaiy  by 
omitting  that  word,  and  speaking  of  "closing  up"  or  "sewing  a  tear,"  for 
instance,  until  the  patient  has  become  accustomed  to  the  idea.  Many  a 
patient  have  I  in  past  years  frightened  away  b^  incautiously  telling  her 
that  an  "  operation  "  would  have  to  be  performed. 

In  the  same  class  of  patients  the  question  should  be  considered  whether 
the  administration  of  an  anesthetic  is  advisable,  and  whether  the  ojDera- 
tion  will  be  likely  to  increase  or  diminish  the  mental  symptoms.  If  the 
fear  of  the  operation  is  so  great  as  to  arouse  permanent  mental  disturb- 
ance, of  course  it  must  be  postponed  or  given  u-p.  On  the  other  hand, 
we  may  often  hope  for  an  improvement  in  the  psychosis  from  the  opera- 
tion, even  though  the  lesion  for  which  the  latter  is  performed  cannot  be 
looked  ujDon  in  the  light  of  its  cause  ;  as,  for  instance,  the  removal  of  cica- 
tricial tissue  at  the  perineum,  and  the  closure  of  a  gaping  vulvar  orifice, 
which  had  produced  marital  infelicity,  sterility,  and  melancholia  on  the 
part  of  the  wife,  or  the  excision  of  a  cicati'icial  x^lug  from  a  cei-idcal  rent 
and  closure  of  that  rent,  which  had  induced  general  and  cerebral  anemia 
with  its  concomitant  neuroses.  The  moral  effect  of  an  operation  should 
also  be  taken  into  account  in  forming  an  indication,  although  too  much 
stress  should  not  be  laid  on  this  reason  to  the  overshadowing  of  the  phys- 
ical condition.  No  doubt  much  good  might  be  done  by  the  judicious 
and  discriminating  operative  treatment  of  female  insane  joatients  whose 
genital  organs  display  some  defect  curable  by  operation,  prorided  the  case 
be  not  of  too  long  standing. 

As  regards  the  advisability  of  administering  an  anesthetic  in  operations 
which  are  ordinarily  comparatively  painless,  or  which  last  but  a  few  mo- 
ments, I  have  in  the  course  of  years  arrived  at  the  conclusion  that,  as  a 
rule,  the  shock  to  the  nervous  system  of  even  a  moderate  amount  of  pain 
and  the  dread  of  sufiering  are  entirely  out  of  proportion  to  the  inconven- 
ience and  expense  of,  and  subsequent  nausea  from,  the  anesthetic.  Hence 
I  now  seldom  perform  a  minor  operation  on  the  female  genitals,  such  as 
curetting,  discision  of  the  uterine  canal,  the  application  of  a  strong  caustic 


8  INTEODUCTION". 

like  nitric  acid  or  tlie  actual  cauterj-,  or  trachelon-hapliy,  -without  an  anes- 
thetic, operating,  of  course,  at  the  patient's  residence.  Only  -where  organic 
disease  of  the  heart  or  lungs  renders  anesthesia  hazardous,  -would  I  per- 
form the  above  operations  on  a  conscious  j^atient. 

The  advanced  age  of  a  patient  should  not  deter  us  from  insisting  on  an 
examination  -sv-henever  it  may  appear  desirable.  Particularly  should  -women 
be  taught  that  the  climacteric  age,  -while  not  in  itseK  serious  or  dangerous, 
still  has  been  found  by  experience  to  be  especially  favorable  to  the  devel- 
opment of  malignant  disease  ;  and  that,  therefore,  the  slightest  derange- 
ment, the  least  excess  of  menstrual  flow  or  leucorrheal  discharge  may  be 
the  first  indication  of  serious  or  fatal  disease,  which  can  only  be  detected 
by  an  examination,  and  Avhose  only  chance  of  cure  consists  in  that  exami- 
nation being  as  early  as  possible.  Neither  should  the  age  of  a  patient 
deter  us  from  an  operation  -n^hich  appears  justifiable  either  through  the 
inconvenience  or  danger  of  her  disease,  the  inability  of  relieving  her  by 
other  means,  or  the  hope  of  prolonging  her  life.  Ovariotomy  has  been 
successfully  performed  after  the  seventieth  year.  In  cases  of  j)rolapsus 
uteri,  ho-v\'ever,  it  may  be  questionable  -whether  it  is  worth  while,  in  view 
of  the  usual  merely  temporary  results  following  the  operations  for  that 
deformity,  to  subject  a  patient  of  over  sixty  years  to  the  operation.  If  a 
bandage  or  contrivance  can  be  found  which  will  retain  the  organ  within 
the  vulva,  an  operation  is  scarcely  called  for.  However,  the  decision  will 
depend  on  the  features  of  each  individual  case. 

The  peculiar  situation  of  the  internal  female  organs  of  generation,  the 
large  networks  of  vessels  surrounding  them,  the  sensitive  character  of  the 
connective  tissue  in  which  they  are  encased,  and  chiefly  the  proximity  of 
the  peritoneum,  render  their  examination  and  treatment  a  matter  of  diffi- 
culty and  danger.  It  should  be  remembered  that,  while  the  uterus  has 
the  reputation,  and  justly  so,  of  being  the  most  patient  and  the  toughest 
organ  in  the  body,  it  or  its  surroundings  will  at  times  resjDond  severely  to 
the  slightest  interference.  While  one  uterus  will  bravely  bear  the  aj)pli- 
cation  of  concentrated  nitric  acid  to  its  interior  or  the  excision  of  a  fibroid 
from  its  wall,  another  will  react  acutely  on  the  introduction  of  a  sound  or 
even  bimanual  palpation.  "While  one  peritoneum  will  not  mind  the  sepa- 
ration of  adhesions  and  the  contamination  of  j)utrid  ovarian  fluid,  another 
will  respond  by  a  furious  inflammation  to  the  sHght  tension  exerted  on  it 
while  drawing  the  utenas  down  to  the  vulva.  All  this  should  be  borne  in 
mind  in  stating  the  dangers  of  an  operation.  Furthermore,  we  should 
consider  that  the  j^revious  existence  of  chi'onic  or  subacute  peri-  or  para^ 
metric  inflammation  renders  the  parts  vastly  more  liable  to  a  return  of 
such  inflammation,  the  extent  of  which  cannot  be  foreseen.  As  a  rule,  the 
presence  of  evidences  of  previous  inflammation  of  the  peri-  or  parametrium 
should  be  looked  upon  as  a  counter-indication  to  active  operative  measures 
or  to  iriitating  applications  to  the  uterus,  and  all  inflammatory  residue 
should  be  removed  or  rendered  inert  (cicatricial)  by  appropriate  treat- 
ment before  a  new  operative  procedure  is  ventured  upon. 

The  proximity  of  the  bladder  and  the  rectum  may  also  serve  to  com- 


GENERAL    CONSIDERATIONS.  0 

plicate  g-ynecological  measures.  The  position  of  the  uterus  varies  physi- 
olooically  with  the  fulness  or  emptmess  of  the  bladder  and  rectum,  and 
the'necessity  for  evacuating  the  contents  of  both  these  organs  at  stated 
intervals  naturally  interferes  more  or  less  with  the  process  of  restoration 
after  operations  on  these  parts.  Thus,  the  catheter  needs  to  be  passed 
re"-ularly,  or  the  urine  allowed  to  flow  over  a  freshly  united  perineum, 
which  latter  occurrence  has  long  been  su^^posed  to  prevent  union  ;  more 
recent  experience  has  shown,  however,  that  healthy  urine  does  not  inter- 
fere with  the  healing  of  fresh  wounds — witness  lithotomy  wounds.  Then, 
the  passage  of  firm  scybalous  masses  may  sunder  a  freshly  healed  peri- 
neum. Inflammatory  edema,  after  operations  on  the  genitals,  may  extend 
to  the  urethra  and  cause  retention  of  urine  ;  or  the  introduction  of  puru- 
lent matter  into  the  bladder  on  the  catheter  may  produce  cystitis.  The 
constant  rhythmic  motion  of  the  uterus  and  anterior  vaginal  wall  with 
each  inspiration  and  expiration  may  annoy  the  inexperienced  operator,  and 
great  difficulty  is  often  met  with  in  separating  the  lax,  rugous  walls  of 
the  vagina  sufficiently  to  gain  a  clear  view  of  the  field  of  operation. 
Great  compensating  advantage  is  gained,  on  the  other  hand,  in  precisely 
such  cases,  as  indeed  in  all  where  the  normal  mobihty  of  the  uterus  is  pre- 
served, by  the  possibility  of  drawing  the  uterus  with  tenacula  down  to  the 
vulva,  and  thus  bringing  it  within  easy  reach  of  the  operator. 

These  general  remarks  on  the  peculiar  features  of  gynecological  tech- 
nics might  be  largely  extended,  but  other  special  points  will  be  referred 
to  in  the  separate  chapters.  In  closing  this  section,  I  will  merely  impress 
upon  the  practitioner  and  embryo  gynecologist  this  one  cardinal  rule  : 
Never  omit  to  make  a  vaginal  examination  whenever  the  symptoms  point 
in  the  least  degree  to  possible  disease  of  the  sexual  organs  ;  consider,  that 
it  is  as  unscientific  and  irrational  to  attempt  to  diagnose  or  treat  sensibly 
an  affection  of  these  organs  without  a  thorough  examination,  as  it  would 
be  in  the  case  of  the  lungs  or  any  other  portion  of  the  body.  This  cau- 
tion will  not  appear  unnecessary  to  those  members  of  the  profession  who, 
as  I  do,  frequently  meet  with  cases  of  long-standing  uterine  disease, 
which  have  been  treated  (Heaven  save  the  mark !)  for  years  and  years  by 
general  practitioners  without  a  local  examination  ever  having  been  pro- 
posed. 


PART    I. 
GYNAECOLOGICAL   EXAMINATION. 


1.    VERBAL  EXAMINATION. 

When  a  female  patient  consults  a  physician  in  general  practice  the 
probability  is  that  the  latter  will  inquire  into  her  sjTnptoms  without  spe- 
cial reference  to  any  set  of  organs,  and,  having  no  specialty,  will  treat  her 
by  general  remedies  to  the  exclusion  of  the  very  means  which  her  condi- 
tion requires.  On  the  other  hand,  the.  speciahst  in  uterine  disease  is  too 
prone  to  ignore  the  influence  of  derangement  of  other  organs  on  the  sex- 
ual system,  and  to  look  upon  the  uterus  and  ovaries  as  the  fountain-head 
of  all  other  diseases  in  the  female  sex.  Both  parties  are  manifestly  in  the 
wi-ong  ;  the  general  practitioner  who  treats  a  leucorrhea,  arising  from  lacer- 
ated cervix  and  endotrachehtis,  by  iron  and  simple  cleansing  injections, 
or  the  sacralgia  of  a  retroverted  uterus  by  a  plaster  to  the  back  ;  and  the 
specialist  who  attempts  to  check  a  menon-hagia  dependent  on  plethora  of 
the  portal  system  by  intra-uteiine  sty[Dtics,  or  cure  ihe  amenorrhea  of  chlo- 
rosis by  local  irritants.  Both  the  too  general  and  the  too  specialistic 
course  should  be  avoided,  and,  in  taking  the  histoiy  of  a  patient,  all  the 
signs  should  be  carefully  noted  which  are  in  any  way  abnormal  or  point  to 
the  possible  seat  of  disease.  In  no  case  should  the  gynecologist  per- 
sist in  attributing  all  the  constitutional  symptoms  to  the  sexual  organs 
when  a  careful  examination  has  failed  to  show  him  any  distinct  sign  of  dis- 
ease in  those  organs.  The  determination  of  the  precise  amount  of  influ- 
ence of  an  areolar  hyperplasia  of  the  utenis,  or  so-called  chronic  metritis, 
in  the  production  of  the  pecuHar  neuroses  and  psychoses  so  frequently  met 
vrith  in  that  common  affection  will,  in  my  opinion,  prove  one  of  the  hardest 
tests  of  his  discrimination  and  judgment  in  this  respect. 

For  the  benefit  of  those  gentlemen  whose  tendency  toward  some  other 
than  the  g;\Tiecological  specialty  might  lead  them  to  overlook  the  existence 
of  uterine  disease,  I  will  refer  to  two  highly  instmctive  cases  which  have 
come  under  my  notice  within  the  last  few  years.  In  one,  the  young  lady, 
after  a  severe  fall  on  her  nates,  began  to  show  signs  of  mental  derange- 
ment, which  gTaduaHy  developed  into  settled  melanchoha  ;  after  no  im- 
provement from  a  six  months'  stay  in  a  celebrated  institution  in  a  neigh- 
boiing  city,  she  consulted  one  of  oui-  rising  young  nem'ologists  nearer 
home,  who  again  failed  to  reheve  her.     Finally,  acting  on  the  advice  of 


VERBAL   EXAMINATION.  11 

some  friends,  she  consulted  a  notorious  female  in-egular,  whose  "  specialty  " 
is  female  diseases.  The  inevitable  examinatioa  followed,  a  retroversion 
was  readily  detected,  the  uteinis  replaced  and  retained  by  an  ordinary  pes- 
sary, and  lo  and  behold  !  in  three  weeks  the  lady's  melancholia  disap- 
peared, and  she  retm-ned  home  well;  of  her  continued  good  health  I 
myself  am  a  frequent  witness.  The  other  case  was  that  of  a  lady  confined 
to  her  bed  for  several  years  by  an  apparent  paresis  of  the  lower  extremi- 
ties, for  which  various  celebrated  neurologists  had  treated  her  in  vain. 
She  chanced  to  fall  into  the  hands  of  one  of  our  younger  gynecologists, 
who  suspected  possible  uterine  disease,  examined,  found  a  retroflexion,  re- 
placed the  uterus,  introduced  a  pessary,  and  in  a  few  days  the  paralytic  pa- 
tient walked ! 

In  taking  the  history  of  a  female  patient  complaining  of  sexual  disease  the 
physician  should,  following  the  usual  inquiries  after  name,  age,  residence, 
nationality,  ascertain  the  occupation  of  the  patient,  whether  it  is  very  labori- 
ous, or  the  contrary,  whether  it  is  such  as  is  likely  to  exert  any  particular 
influence  on  the  sexual  organs,  such  as  the  habitual  use  of  the  sewing- 
machine.  Further,  he  should  inquire  if  the  patient  is  married,  if  so,  how 
long,  how  many  children  she  has  had,  how  many  miscaniages  ;  how  long 
since  her  last  confinement  or  miscarriage  ;  whether  all  her  labors  and  get- 
tings-up  were  easy  and  natural ;  whether  instruments  were  used  ;  how  long 
she  has  been  in  poor  health  ;  what  diseases  she  has  had  ;  whether  her  par- 
ents were  healthy.  He  should  then  inquire  about  her  menstrual  function, 
at  what  age  it  first  appeared,  whether  it  was  always  regular,  its  duration 
and  character,  its  freedom  from  pam,  or  the  reverse  ;  when  it  last  occurred. 
The  last  question  should  never  be  omitted,  as  there  can  be  no  doubt  that 
many  a  sound  has  been  hun-iedly  passed,  and  an  abortion  thereby  pro- 
duced, simply  because  the  patient  was  not  induced  to  tell  that  she  had 
gone  one,  two,  or  more  weeks  over  a  menstrual  period.  True,  the  woman 
may  intentionally  make  a  misstatement  on  this  subject ;  but  then,  at  least, 
the  physician  is  exonerated  so  long  as  the  slight  increase  in  size  of  the 
uterus  does  not  enable  him  to  detect  the  early  pregnancy.  The  patient 
should  further  be  ciuestioned  as  to  the  seat,  character,  duration,  and  per- 
sistency of  any  pain  she  may  experience  ;  if  she  is  manied,  as  to  whether 
coition  is  painful ;  whether  she  has  a  vaginal  discharge,  its  amount,  char- 
acter, and  duration  ;  whether  micturition  is  free,  abundant,  or  painfiil ;  the 
condition  of  her  bowels,  whether  regular,  constipated,  or  painful ;  as  to 
her  appetite  and  digestion,  and  her  general  health  ;  the  presence  of  heredi- 
tary disease  in  the  family  ;  the  suffering  of  the  patient  fi-om  chlorosis 
during  her  early  menstrual  life,  or  the  prerious  occurrence  of  perimetric 
inflammation,  are  particularly  important  data.  In  old  patients  the  time 
and  character  of  the  menopause  should  be  inquired  into. 

In  estimating  the  usually  long  array  of  symptoms  presented  by  a  pa- 
tient sufiering  from  sexual  disease,  it  behooves  the  physician  to  take  heed 
of  any  and  aU  symptoms,  no  matter  how  apparently  abstract,  which  his 
reading  or  experience  have  taught  him  may  have  a  possible  connection 
with  the  disorder  for  which  he  is  consulted,  and  to  endeavor  to  give  them 


12  GYNECOLOGICAL    EXAMINATION. 

tlieii'  proper  origin  and  value.  The  disorders  of  nutrition  and  innervation 
"wliicli  occur  so  commonly  in  utero-ovarian  disease  as  to  be  properly  con- 
sidered as  more  or  less  dependent  upon  it — tlie  hystero-neuroses,  to  use 
the  comprehensive  and  convenient  term  of  Engelmann — are  met  with  in 
almost  every  organ  and  tissue  of  the  body,  and  in  many  cases,  if  still  in 
their  early  stages,  yield  spontaneously  with  the  improvement  in  the  genital 
affection.  Still,  it  will  generally  be  found  advisable,  both  as  a  comfort  to 
the  patient  and  a  means  of  retaining  her  confidence,  to  treat  such  symp- 
toms in  other  organs  as  seem  to  require  special  remedies.  Such  hystero- 
neuroses  are  :  dyspepsia,  chiefly  belching,  cardialgia,  nausea,  loss  of  ap- 
petite (a  common  accompaniment  of  ovarian  congestion)  ;  tympanites  ; 
hemicrania,  general  cephalalgia,  mammary,  intercostal,  and  other  neural- 
gise ;  the  various  hysterical  symptoms,  globus  hystericus,  general  nervous- 
ness, hiccup,  fits  of  laughing  and  weeping,  convulsive  actions,  paralyses ; 
cutaneous  emptions,  acne,  chloasma,  eczema.  A  frequent  occurrence  is  the 
enlargement  and  tenderness  of  the  breasts  during  menstruation  and  uterine 
disease  mainly  justbeforethemenstrual period,  especiallyif  the  flowis  scanty. 

The  symptoms  which  chiefly  attract  the  attention  of  the  jjhysician  to 
the  pehic  organs  are  :  sensation  of  weight  or  bearing-down,  or  falling  in 
the  abdomen  and  pelvis,  a  pain  in  the  hypogastric,  ingminal,  or  sacral 
regions  ;  darting  or  radiating  pains  from  the  pubis  down  the  thighs,  or  into 
the  inguinal  or  hy2:)ochondriac  regions  ;  pain  on  defecation  and  micturi- 
tion ;  dyspareunia  ;  inability  to  take  even  moderatel}^  long  walks  or  to  go 
up  and  down  stairs  ;  pelvic  pain  on  sitting  ;  itching  of  the  external  geni- 
tals ;  leucorrhea ;  amenorrhea,  or  dysmenorrhea  ;  meno-  or  metron-hagia. 
To  ascertain  the  aj^proximate  amount  of  blood  lost  the  best  way  is  to 
inquu'e  how  many  napkins  (provided  she  uses  them)  the  patient  soaks 
through  every  day.  In  estimating  the  value  of  leucoiThea  as  a  symptom 
it  should  be  remembered  that,  with  the  exception  of  cases  of  general  anemia, 
it  is  merely  a  symj)tom  indicative  of  more  serious  disease,  and  not  the 
disease  itself ;  also,  that  the  character  of  the  discharge,  whether  w^hitish, 
greenish,  sanguineous,  serous,  ropy,  or  offensive,  is  of  importance  in  indi- 
cating the  seat  and  nature  of  the  internal  affection. 

The  importance  of  recognizing  and  aj)preciating  the  significance  ofjMin 
as  a  means  of  diagnosis  of  pelvic  disease  in  the  female  leads  me  to  say  a 
few  words  on  this  subject. 

As  a  rule,  pain  in  the  lower  part  of  the  abdomen  or  the  pelvis  of  a 
woman  indicates  that  she  is  the  rictim  of  some  functional  or  organic  dis- 
order of  one  of  the  organs  contained  in  these  cavities.  It  by  no  means 
follows,  however,  that  pain  in  other  portions  of  the  body  should  not  be 
referable  to  the  pelvic  organs.  Pain  in  the  suprapubic  region  generally 
denotes  chronic  or  subacute  enlargement  (hyperplasia  or  subinvolution)  of 
the  uterus.  If  the  sensation  is  spoken  of  more  as  that  of  motion,  "as 
though  a  child  were  moving  about  in  the  abdomen,"  I  have  found  it  to 
indicate,  with  almost  unerring  certainty,  the  presence  of  hj-perplasia  or 
subinvolution  of  an  aggi'avated  degree.  This  peculiar  sensation  is  jorobably 
a  hystero-neui'osis,  although  it  may  often  be  due  to  increased  peristaltic 


VERBAL    EXAMINATION.  13 

action  of  the  intestines.  Such  action  must,  however,  generally  be  irregular 
or  spasmodic,  since  these  patients  are  almost  invariably  constipated,  -which 
■would  not  be  the  case  if  normal  peristalsis  were  really  increased.  If  the 
feeling  is  that  of  weight,  weakness,  or  forward  pressure,  an  anteversion  or 
anteflexion,  with  or  without  moderate  descensus,  may  generally  be  expected. 
If  there  is  bearing-down,  a  feeling  "as  though  everj'thing  were  going  to 
drop  out,"  descensus,  a  prolapsus,  or  retroversion  or  flexion  will  probably  be 
found,  or  a  cystocele  or  rectocele  may  produce  a  similar  sensation. 

A  dragging,  aching  pain  in  either  groin,  extending  down  the  thighs, 
generally  depends  on  prolapsus  and  retrodisplacement.  Expulsive  pains 
in  the  uterine  region  denote  a  desire  on  the  part  of  the  uterus  to  expel 
some  foreign  body,  such  as  a  fibroid,  a  detached  ovum,  retained  menstrual 
fluid.  Pain  in  the  ovarian  region  does  not  always  indicate  disease  of  the 
ovaries,  for  it  very  frequently  is  of  reflex  character,  depending  on  inflam- 
mation, laceration,  or  hyperplasia  of  the  cervix.  Still,  when  we  find  a 
more  or  less  acute  boring,  often  darting,  shooting  pain  in  that  region  com- 
plained of,  we  can  generally  expect  to  find  the  ovary  enlarged  and  con- 
gested, or  prolapsed  ;  in  the  latter  case  the  pain  is  generally  deeper-seated, 
and  extends  to  each  hip  or  sacro-ischiatic  notch.  If  the  ovaries  are  the 
seat  of  pain,  the  latter  will  be  found  to  be  aggravated  just  before  the  men- 
strual period. 

Pain  in  tlie  back,  if  in  the  lumbar  region,  generally  has  no  du-ect 
connection  with  utero-ovarian  disease.  It  may,  however,  possibly  denote 
in  cystitis  a  spread  of  the  catarrhal  disease  up  the  ureters  to  the  renal 
pelves. 

If  in  the  sacrum,  however,  the  pain  generally  gives  rise  to  a  suspicion 
of  a  retrodisplacement  of  the  uterus,  or  of  prolapse  of  one  or  both  ovaries  ; 
or  an  acute,  subacute,  or  (so-called)  chronic  perimetxic  inflammation.  In 
the  latter  class  of  cases  it  by  no  means  follows  that  the  plastic  exudation 
is  of  great  amount,  forming  an  actual  tumor ;  while,  as  a  rule,  the  sacral- 
gia increases  in  proportion  to  the  size  and  extent  of  the  exudation.  I  have 
seen  more  diffuse  infiltration  and  cicatricial  induration  of  the  retro-ute- 
rine cellular  tissue  and  peritoneum  accompanied  by  the  most  intense,  con- 
tinuous sacral  pain.  In  some  cases  nothing  but  a  diffuse,  boggy  condi- 
tion of  the  retro-uteiine  tissue  will  be  found  to  account  for  the  i^aiu,  which 
may,  perhaps,  be  looked  upon  as  edema  of  the  cellular  tissue,  or  subacute 
sacral  periostitis.  Recent  observations  lead  me  very  much  to  believe  that 
a  subacute  or  chronic  inflammation  of  the  lymphatic  glands  and  vessels 
of  the  pelvic  cellular  tissue — an  adenitis  and  angioleucitis — is  the  true 
pathology  of  many  of  these  cases.  They  certainly  are  exceedingly  obsti- 
nate to  treatment.  Very  frequently  nothing  whatever  will  be  found  to 
account  for  the  sacralgia,  which  we  are  then  forced  to  consider  a  veritable 
reflex  neuralgia  proceeding  from  a  hyperplastic  uterus  or  congested  ova- 
ries, and  which  is  often  benefited  b}^  counter-irritant  applications  to  the 
skin  of  the  sacrum  and  lumbar  region.  Occasionally  the  "  backache  "  is 
lower  down  toward  the  coccyx,  and  wiU  be  found  to  dejDend  on  a  catarrhal 
inflammation  of  the  rectum.     Pain  on  defecation  may  be  caused  by  a  retro- 


14  GYNECOLOGICAL    EXAMINATIOISr. 

displaced  inflamed  uterus  or  ovary  (particularly  the  latter,  when  the  pain 
lasts  for  some  time  after  the  passage),  or  by  an  ulcer  in  the  rectum,  or  by 
a  fissure  at  the  anus,  or  by  hemorrhoids. 

I  have  met  with  a  number  of  cases  in  which  the  pressure  of  the  hard 
cervix  of  a  hypei-plastic  and  partly  prolapsed  uterus  on  the  posterior  wall 
of  the  vagina  caused  severe  pain  near  the  jvmction  of  the  sacrum  and 
coccyx.  Occasionally  the  coccygodynia  is  due  to  dislocation,  or  anterior 
anchylosis  of  the  coccyx ;  in  some  cases  caries  or  necrosis  of  the  bone  is 
present,  and  in  others  there  appears  to  be  a  simple  neuralgia  of  the  bone. 

A  pecuhar  pain  in  the  hij),  somewhat  above  the  ischiatic  notch,  is  fre- 
quently indicative  of  ovarian  disease  ;  a  bhster  over  the  painful  spot  may, 
however,  relieve  the  j)ain  and  prove  it  to  be  merely  sciatica. 

Pain  in  micturition,  if  it  be  of  a  scalding  character,  generally  indicates 
acute  cystitis  or  urethritis,  or  a  highly  acid  state  of  the  urine,  which  is 
often  due  to  cold  and  requires  merely  warmth  and  diluent  or  alkaline 
drinks  to  cure  it ;  if  spasmodic  (tenesmus)  there  may  be  a  fissure  or  carun- 
cle of  the  urethra,  or  merely  a  h^'peresthetic  condition  of  the  circular 
fibres  of  the  neck  of  the  bladder  induced  by  chronic  cystitis.  The  latter 
condition  is  particularly  distressing  and  obdurate.  Prolapse  of  the  floor 
of  the  bladder  (cystocele)  or  sacculation  of  the  urethra  (urethrocele) 
may  also  give  rise  to  jDain  and  delay  in  micturition. 

Frequent,  not  painful,  micturition,  chiefly  during  the  day-time  and 
when  the  patient  is  on  her  feet,  may  be  due  to  a  slight  exposure  to  cold, 
or  to  too  active  or  prolonged  exercise,  but  if  it  persists  longer  than  a  few 
days  it  will  generally  be  found  to  be  dependent  on  anteversion,  anteflexion, 
or  antecurvature  of  a  more  or  less  enlarged  uterus.  The  influence  of 
nervous  excitement  in  producing  enui-esis  should,  however,  not  be  forgot- 
ten. One  of  my  patients  always  suffers  from  intense  tenesmus  of  the 
bladder  for  several  days  after  coition,  which  act,  therefore,  is  torture  to 
her.  As  she  has  an  anteversion,  the  cervix  being  attached  by  adhesions 
to  the  rectum,  and  a  chronic  ovaritis,  the  vesical  irritation  is,  no  doubt, 
produced  directly  by  the  forcing  back  of  the  cervix,  and  sharp  tilting  for- 
ward of  the  fundus  on  the  neck  of  the  bladder  during  each  intromission. 

Pain  in  the  vulva  generally  means  some  inflammatory  or  ulcerative  con- 
dition of  the  labia  or  introitus  vaginae,  such  as  simple  vulvitis,  or  follicu- 
litis vulvae,  or  inflammation  of  the  Bartholinian  gland,  or  chancroid  or 
some  other  injury  or  disease.  It  should  lead  us  always  to  inspect  the 
vulva  before  proceeding  to  indagation. 

Pain  in  the  legs,  if  down  the  anterior  aspect  of  the  thighs,  may  denote 
downward  or  forward  displacement  of  the  uterus;  if  down  the  back  of  the 
thighs,  retrodisplacement  of  uterus  or  ovaries,  or  cellulitic  deposits,  Avhich 
exert  pressure  on  the  sacral  ners^es.  I  have  recently  seen  a  lady,  who  was 
referred  to  me  by  one  of  our  most  distinguished  neurologists,  under  whose 
care  she  had  been  for  "  spinal  irritation,"  in  whom  every  examination  pro- 
duced the  most  peculiar  symptoms  of  reflex  neuralgia  ;  passing  the  finger 
through  the  vaginal  introitus  caused  pain  in  both  thighs,  chiefly  when  a 
sensitive  hymeneal  caruncle  near  the  navicular  fossa  was  touched,  and 


VERBAL    EXAMIISTATION.  15 

friction  of  the  cervix  with  the  finger  excited  pain  in  and  contractions  of 
the  sphincter  ani.  Retraction  of  the  perineum  with  Sims'  speculum  was 
followed  with  so  severe  pains  and  apparent  loss  of  power  in  both  legs  as 
to  render  her  almost  unable  to  walk  for  several  hours.  No  doubt  the  hy- 
peresthetic  condition  of  the  lower  portion  of  her  sj)inal  cord  had  some- 
thing to  do  with  these  phenomena. 

Pain  in  the  intercostal  spaces  very  often  depends  on  ovarian  disease, 
and  is  more  frequently  connected  with  the  left  ovary,  and  therefore  also 
met  with  as  cardialgia.  Hemicrania  (migraine)  and  pressure  on  the  vertex 
and  occiput  are  very  commonly  met  with  in  connection  with  menstrual 
disorders,  or  occur  at  the  time  of  menstruation,  particularly  if  the  flow  is 
scanty. 

Pain  in  the  epigastric  region  is  one  of  the  commonest  symj)toms  in 
uterine  disease  next  to  the  local  signs.  It  shows  the  intimate  relation  be- 
tween the  sexual  and  the  digestive  organs,  and  generally  depends  on  func- 
tional derangement  of  the  stomach.  Vomiting  is  less  frequently  met  with 
— nausea  more  so — and  should  lead  the  physician  to  inquire  j^articularly 
about  the  time  of  the  last  menstruation  and  suspect  pregnancy,  esiDecially 
if  it  occur  chiefly  in  the  morning.  In  some  patients  nausea  and  vomiting 
are  caused  by  j^ressure  on  a  congested  or  inflamed  ovary.  I  have  thus 
repeatedly  produced  it  at  wall. 

Pain  is  very  often  changed  or  aggravated  by  walkiug,  standing,  lying 
or  sitting  down.  This  is  particularly  the  case  in  disj)lacements  (even  in 
anteflexions  in  young  girls  the  suprapubic  pressure  and  discomfort  is  in- 
creased thereby)  and  pelvic  inflammation.  An  increase  of  pain  in  sitting- 
down  would  indicate  that  pressiu-e  w^as  exerted  on  an  organ  in  that  posi- 
tion, and  not  in  the  erect  posttu-e  ;  thus  a  prolapsed  and  congested  ovary 
would  natiu-ally  be  squeezed  between  the  uterus  and  pelvic  wall,  by  the 
downward  pressure  of  the  intestines  in  the  sitting  posture — I  have  such  a 
case  in  mind — or  an  inflamed,  carious,  or  hyperesthetic  coccyx,  or  pro- 
lapsed and  inflamed  hemorrhoid  would  manifest  itself  by  pain  chiefly  when 
pressure  is  made  directly  upon  it  when  the  patient  sits  do^\Ti.  Again,  a 
patient  with  an  inflamed  ovary,  or  an  acute  pehic  exudation,  would  not  be 
able  to  he  on  the  affected  side,  because  the  pressui-e  of  the  superincumbent 
viscera  increases  the  pain. 

I  have  akeady  stated  that  pain  as  a  diagnostic  symptom  of  utero-pelvic 
disease  is  of  great  value.  Still,  it  is  by  no  means  implicitly  to  be  rehed 
upon,  and  should  be  utilized  only  as  an  auxiliary  or  guide  to  diagnosis. 
Thus,  I  have  frequently  found  women  who  complained  of  the  most  acute 
abdominal,  sacral,  and  general  pain,  present  absolutely  nothing  but  a  mod- 
erate hyperplasia  uteri  (these  pains  were  evidently  hystero-neurotic) ;  and 
again  patients  with  scarcely  a  local  symptom  have  surprised  me  by  the 
discovery  of  a  severe  displacement,  laceration,  or  even  malignant  disease. 
The  peculiar  character  of  the  pain  is  also  misleading  ;  thus,  I  recollect  one 
case  of  a  woman  who  consulted  me  for  a  constant  sanguineous  discharge, 
saying  that  she  had  expulsive  pains  like  labor  pains.  I  remarked  to  my 
students  that  a  continual  sanguineous  flow  in  a  woman  of  her  advanced 


16  GYNECOLOGICAL    EXAMINATION. 

age  would  lead  me  to  suspect  malignant  disease,  but  that  the  expulsive 
pains  were  much  more  characteristic  of  fibroid,  probably  a  polypus.  An 
examination,  howevei^,  revealed  a  large  epithelioma  of  the  cervix. 

Pain  during  menstruation  is  very  common,  particularly  in  unmarried 
women  and  nulliparae.  If  occurring  before  the  flow,  it  generally  denotes 
ovarian  congestion,  if  at  the  inception  of  or  during  the  flow  some  obstruc- 
tion to  the  free  discharge  of  the  blood,  such  as  constricted  cervical  canal, 
or  flexion.  Since  the  majority  of  women  experience  more  or  less  local  and 
constitutional  discomfort  immediately  preceding,  and  less  frequently  during 
the  menstrual  flow,  the  physician  must  be  guided  by  the  intensity  of  the 
symptoms  in  deciding  on  the  necessity  for  treatment.  A  very  peculiar  pain 
occurring  about  the  middle  of  the  intermenstrual  period  is  not  unfrequently 
comjDlained  of  ;  it  closely  resembles  that  experienced  by  the  same  indi- 
vidual at  the  regular  epochs,  and  is  generally  accompanied  by  increased 
genital  secretion.  It  has  been  called  by  Priestley,  who  was  one  of  the  first 
to  describe  it,  "intermenstrual  dysmenorrhea,"  and  appears  to  depend 
either  on  intermediate  ovulation  or  on  inflammatory  exacerbations  in  the 
ovaries.  It  is  frequently  accompanied  by  anteflexion  and  chronic  peMc 
peritonitis,  and  I  have  seen  one  case  in  a  virgin  in  which  there  was  merely 
a  slight  descensus  uteri,  the  relief  of  which  by  a  pessary  entirely  removed 
the  pain. 

The  causative  agencies  of  the  symptoms  ascertained  during  a  verbal 
examination  should  be  carefully  inquired  into  under  the  head  of  general 
or  predisposing,  and  direct  or  local  causes.  The  predisposing  consist  of 
previous  ill-health,  hereditary  tendency,  over-exertion,  too  frequent  labors 
and  too  early  gettings-up,  masturbation,  tight  lacing,  confining  or  pecul- 
iarly injurious  work  (sewing-machine),  too  luxurious  life,  etc.  ;  the  direct, 
of  local  injuries  by  parturition,  criminal  abortion,  too  frequent  or  unnat- 
ural coition,  injections,  pessaries,  cauterization,  exposure  to  cold  or  sudden 
violence,  and  particularly  the  puerperal  state. 

To  guard  against  omitting  important  points  the  physician  will  do  well 
to  foUow  a  specified  order  in  asking  questions  and  learning  the  history  of 
the  patient,  in  which  task  he  should  endeavor  to  adapt  himself  to  the  pa- 
tient's way  of  telling  her  storj'. 

All  the  symptoms,  local  and  general,  having  been  systematically  ascer- 
tained and  noted,  the  physician  should,  if  the  information  obtained  war- 
rants it,  propose  a  vaginal  examination  with  the  precautions  above  speci- 
fied. 

2.    METHODS  OF  LOCAL  EXAMINATION. 

The  peculiar  seat  and  character  of  the  female  generative  organs  re- 
quires for  their  examination  methods  and  maneuvres,  for  the  most  part, 
entirely  different  from  those  employed  in  the  exploration  of  other  organs 
of  the  body.  To  be  sure,  we  make  use  of  the  eye  and  the  ear  in  this  exami- 
nation, but  the  special  use  of  the  finger,  the  speculxim,  and  the  sound,  is 
peculiar  to  a  gynecological  examination. 


LOCAL    EXAMINATION.  17 

The  methods  at  our  disposal  for  the  local  examination  of  the  female 
generative  organs  are  the  following  : 

I.    NON-INSTEUMENTAI,   MeTHODS. 

A.  Inspection  of  the  external  genitals  and  abdomen. 

B.  Auscultation  and  percussion  of  the  abdomen. 

C.  Palpation  of  the  abdomen. 

D.  Digital  examination  ;  a,  vaginal ;  b,  rectal ;  c,  vesical. 

E.  Conjoined  examination  ;  a,  vagino-abdominal ;  h,  recto-abdominal ; 
c,  vesico-abdominal. 

F.  Digital  eversion  of  rectum. 

II.    iNSTKtfMENTAIi. 

A.  Exploration  of  urethra  and  bladder  with  catheter,  sound,  or  en- 
doscope. 

B.  Examination  of  the  vagina,  cervix,  and  external  os  with  the  spec- 
ulum. 

C.  Examination  of  the  uterus  with  the  sound  and  probe. 

D.  Dilatation  of  the  uterus  for  purposes  of  diagnosis. 

E.  Examination  of  the  uterus  with  the  blunt  curette. 

r.  Artificial  prolapsus  of  the  uterus  for  diagnostic  purposes. 

G.  Examination  of  the  rectum  with  the  speculum. 
H.  Mensuration  of  the  abdomen. 

I.     Aspiration  of  pelvic  and  abdominal  tumors. 

It  is  evident  that  the  greater  portion  of  these  methods  will  be  unneces- 
sary in  the  majority  of  cases,  or  that  the  order  in  which  they  are  employed 
may  be  greatly  modified  by  the  necessities  of  the  occasion.  Thus  inspec- 
tion may  be  deferred  till  the  last,  or  vmtil  the  apphcation  of  the  speculum 
requires  the  exposure  of  the  parts  ;  or  auscultation  and  percussion  are 
entirely  unnecessary,  or  the  vesical  and  rectal  examinations  are  uncalled 
for.  Dilatation  of  the  uterus  would  manifestly  be  required  only  when 
more  simple  and  ready  means  fail  in  establishing  a  diagnosis. 

As  a  rule,  the  order  of  examination  of  a  gynecological  patient  is  the 
following  :  1,  inspection  of  the  external  genitals  ;  2,  examination  with  the 
finger  and  conjoined  manipulation  ;  3,  introduction  of  sound  ;  4,  examina- 
tion with  the  speculum. 

As  it  is  our  duty  to  endeavor  to  gain  as  correct  and  complete  an  idea 
of  our  patient's  condition  as  science  and  her  i:)hysical  and  mental  condition 
allow,  it  is  always  advisable,  unless  counter-indications  (to  be  specified 
hereafter)  exist,  to  employ  all  innocuous  means  in  our  power  in  making  a 
diagnosis.  For  this  reason,  at  a  first  interview,  or  as  soon  thereafter  as 
practicable,  the  sound  and  speculum  should  be  employed,  even  though 
they  may  not  again  be  needed. 

It  is  well  to  accustom  one's  self  to  a  certain  fixed  routine  of  examina- 
tion, but  this  routine  should  always  be  made  to  vary  in  accordance  with 


18  GYNECOLOGICAL    EXAMINATIOIS-. 

the  results  of  previous  statements  and  examinations  ;  thus  we  should  not 
j)ass  the  sound,  when  we  learn  that  the  patient  has  skipped  a  menstrual 
period,  or  lacerate  a  hymen  merely  for  the  routine  purj)ose  of  introducing 
the  speculum. 

A  very  excellent  plan  of  dividing  the  methods  of  examination  is  that  by 
the  exercise  of  the  senses,  thus  : 

a.  Examination  by  touch  :  palpation  ;  indagation  and  conjoined  manip- 
ulation of  vagina,  rectum,  and  bladder ;  introduction  of  the 
sound. 

h.  Examination  by  sight :  inspection,  mensuration,  specula. 

c.  Examination  by  hearing  :  percussion  and  auscultation. 

d.  Examination  by  smell :  the  odor  of  vaginal  discharges,  indicative 

of  infectious  or  malignant  disease,  or  of  communication  with  the 
intestine. 

I  have  preferred  to  classify  the  methods  as  non-instrumental  and  in- 
strumental, as  most  easy  for  systematic  description. 

It  is  needless  to  enjoin  upon  the  examiner  that  the  greatest  gentle- 
ness, dehcacy,  and  refinement  are  of  paramount  importance  in  making  a 
genital  examination,  if  he  would  avoid  increasing  the  distaste  which  the 
patient  naturally  feels  at  the  disagreeable  necessity,  and  insure  her  sub- 
mission to  a  repetition  of  the  process.  All  unnecessary  pain  should  be 
scrupulously  avoided,  and  care  taken  to  leave  as  little  of  an  unpleasant 
effect  on  the  patient's  mind  and  body  as  is  consistent  "svith  the  accomjpUsh- 
ment  of  the  object.  For  this  reason,  instruments  should  be  kej)t  as  much 
out  of  sight  and  hearing  as  jDOSsible,  and  blood-stains  be  carefully  removed 
from  the  vulva,  for  fear  of  exciting  suspicion  and  alarm. 

Whenever  practicable  a  diagnosis  should  be  made  at  the  first  examina- 
tion ;  where  this  is  impossible,  as  manifestly  must  occasionally  occur,  the 
patient  should  be  told  the  reason,  and  a  second  or  third  interview  solicited, 
until  all  doubts  are  removed.  The  diagnosis  and,  eo  ipso,  the  treatment 
may  depend  on  the  result  of  a  microscopic  examination  ;  or  the  fulness  of 
the  bladder  or  rectum,  or  the  excitable  condition  of  the  patient  may  pre- 
clude an  immediate  diagnosis  ;  or  the  imminence  of  the  menstrual  flow,  or 
the  presence  of  perimetric  inflammation  counter-indicate  the  exploration 
of  the  uterus. 

The  most  favorable  time  for  an  examination  is,  as  a  rule,  about  the 
middle  of  the  intermenstinial  period,  and  the  time  of  day  one  when  the 
Hght  is  fair  and  the  patient  under  as  normal  conditions  as  possible. 

3.    POSITIONS  FOR  EXAMINATION. 

The  examination  of  the  female  genital  organs  may  be  undertaken  in 
various  positions  :  a,  dorsal  recumbent ;  h,  lateral ;  c,  latero-abdominal ; 
d,  abdominal  ;  e,  genu-pectoral  ;  /,  erect. 

The  preference  for  one  or  the  other  of  these  positions  varies  in  differ- 
ent countries.     Thus  in  England  the  left  lateral  decubitus  is  generally 


DOESAL    RECUMBENT    POSITION. 


19 


chosen  both  for  digital  and  specular  examination  ;  the  French  and  Gennans 
prefer  the  dorsal  position  for  finger  and  speculum  ;  and  we  in  this  coun- 
try employ  a  combination  ■  of  both  positions,  making  the  digital  examina- 
tion on  the  back,  and  then  turning  the  patient  to  the  left  latero-abdominal 
position  for  the  ajDplication  of  the  duck-bill  speculum.  The  majority  of 
practitioners,  however,  introduce  the  cyhndrical  and  bivalve  specula  on 
the  back. 

It  is  frequently  of  the  greatest  diagnostic  and  therapeutic  utility  to 
examine  a  patient  in  different  positions,  reference  to  which  will  be  made 
under  the  various  heads. 

In  all  the  recumbent  positions  but  the  latero-abdominal  an  ordinary 
couch,  sofa,  or  bed  can  be  made  available  ;  but  for  the  examination  in  the 
latero-abdominal  position  a  hard,  perfectly  level  plane  is  essential.  In 
all  the  j)ositions,  the  nates  should  be  brought  down  to  the  very  edge  of  the 
couch,  whenever  practicable.  In  making  a  mere  digital  examination  while 
the  patient  is  in  bed,  this  rule  is,  of  course,  generally  disregarded. 

a.    Dorsal  Recumbent  Position. 

There  are  several  subdivisions  of  the  dorsal  position  which  all  possess 
theii-  utility  and  may  come  into  play  in  any  case.  They  are :  the  level 
dorsal,  with  head,  shoulders,  sacrum,  and  soles  of  feet  on  the  same  plane, 


Fig.  1. — Dorsal  Recumbent  Position,  with  Extended  Legs.     (Hegar  and  Kaltenbach.) 

thighs  flexed  nearly  at  right  angles  to  abdomen  ;  the  ghdeo-dorsal,  with 
the  thighs  acutely  flexed  on  the  abdomen  and  the  knees  touching  the  tho- 
rax ;  the  lithotomy,  with  the  shoulders  elevated,  so  as  to  approach  the  jjel- 
vis. 

The  dorsal  2^osition,  with  legs  extended,  I  have  not  thought  necessary 
to  enumerate  among  the  positions  for  a  vaginal  examination,  as  this  pro- 
cedm-e  can  only  be  very  im^jerfectly  performed  in  that  position.     The  ne- 


20 


GYNECOLOGICAL    EXAMINATION. 


cessity  for  examining  in  that  position  will  occur  only  in  cases  where 
absolute  immobility  of  the  body  is  imperative  (as  hemorrhage,  violent  j)eri- 
tonitis),  or  where  the  knees  or  hips  are  anchylosed.  Under  all  other  cir- 
cumstances, no  matter  how  inconvenient,  the  patient  can  at  least  flex  the 
knees  as  in  the  regular  position  about  to  be  described.  The  difference 
of  position  of  the  pelvis  and  sexual  organs  is  seen  by  comparing  figures 
1  and  2. 

For  purposes  of  digital  and  bimanual  examination  the  ordinary  level 
dorsal  position  tvith  flexed  knees  is  the  most  convenient.  Its  employment 
by  the  majority  of  gynecologists  proves  this  statement.  In  it  the  pel- 
vic and  abdominal  viscera  are  at  rest,  and  occupy  as  nearly  as  possible 
a  horizontal  position,  gravitating  neither  downward,  nor  laterally,  nor  up- 
ward ;  the  diajDhragm  exercises  a  minimum  of  displacing  power  on  the 


Fig.  2.— Dorsal  Pobition,  with  Knees  Flexed.     (Hegar  and  Kaltenbach.) 

viscera  ;  the  abdominal  wall  is  relaxed  ;  and  we  have  the  pelvic  organs  in 
as  nearly  a  state  of  quiescence  as  we  can  expect  to  find  them.  One  of  the 
great  advantages  of  the  dorsal  position,  next  to  the  probability  of  finding 
the  pelvic  organs  in  the  most  natural  position,  is  the  possibihty  of  exercis- 
ing abdominal  palpation  together  with  indagation. 

The  patient  is  placed  on  a  flat,  perfectly  level  couch,  best  a  table,  her 
head  resting  on  a  low  pillow,  her  shoulders  and  sacrum  on  the  same  level, 
the  nates  close  to  the  edge  of  the  table,  the  feet  close  to  and  slightly  exter- 
nal to  the  thighs,  the  knees  widely  separated.  In  case  of  need  the  knees 
may  have  to  be  kept  asunder  by  assistants.  In  this  position  the  pubis  is 
the  highest  portion  of  the  pelvis;  it  approaches  the  promontory  of  the 
sacrum,  which  rests  on  its  middle  portion  ;  the  vagina  pursues  a  less  hori- 
zontal, more  downward  direction,  than  in  the  flat  dorsal  (Tig.  1).  The 
cervix  is  situated  about  on  a  Hne  drawn  through  the  tuberosities  of  the 


DORSAL    RECUMBENT    POSITIOK. 


21 


ischium.  Two  lines  drawn  from  the  upper  border  of  the  symphysis  and 
the  posterior  commissure  of  the  vulva  respectively,  to  the  promontory  of 
the  sacrum,  form  an  angle  of  fifty-five  degrees. 

In  this  position  the  abdominal  jDarietes  are  more  relaxed,  and  intra-ab- 
dominal pressure  is  more  reduced  than  in  the  flat  dorsal. 

This  position  is  undoubtedly  the  most  convenient  and  practical  for  all 
ordinary  examinations,  and  should  always  be  employed  whenever  the  neces- 
sary hard  level  couch  is  at  hand.  But  it  very  frequently  happens  that  we 
are  obliged  to  examine  patients  in  bed  or  on  office-chairs,  with  head  sup- 
ported by  pillows  or  cushions.  The  thorax  is  then  a]3proximated  to  the 
pelvis  and  a  slightly  different  relation  of  angles  between  the  symphysis, 
promontory,  and  lumbar  vertebral  column  is  established. 

Intra-abdominal  pressure  is  also  somewhat  increased,  whence  this  i^osi- 
tion  is  inferior  to  that  on  a  perfectly  level  plane.  Any  one  who  has  en- 
deavored to  practise  abdominal  palpation  when  the  thorax  was  somewhat 


Pig.  3. — Dorsal  PoBition — Lithotomy.     (Heg.ir  and  Kaltenjaach.) 

elevated,  as  is  usually  the  case  in  bed,  wiU  appreciate  the  difference.  This 
position  is  rather  more  comfortable  for  the  patient  than  any  other,  and  in 
cases  of  no  more  than  ordinary  difficulty  answers  all  purposes.  The  va- 
gina has  an  almost  horizontally  backward  direction,  and  the  symphysis  is 
elevated  but  slightly  above  the  promontory. 

These  two  positions  suffice  for  all  ordinary  vaginal  examinations.  But 
cases  are  not  uncommon  in  which  the  thickness  or  rigidity  of  the  abdom- 
inal walls,  the  length  of  the  vagina,  or  the  i-igidity  of  the  perineum  prevent 
a  thorough  examination.  Li  such  cases  the  dorsal  position  may  be  stiU 
further  modified  by  putting  the  patient  in  the  so-called  fjluteo-dorsal  posi- 
tion (first  systematically  utilized  by  Simon),  which  consists  in  flexing  the 
thighs  of  the  patient  to  their  utmost  extent  on  her  abdomen,  so  as  to  bring 
the  knees  almost  in  contact  with  the  thorax,  and  separating  the  knees  as 
widely  as  possible.  The  vulva  shoiild  be  at  least  at  the  edge  of  the  table. 
Each  leg  is  held  by  an  assistant,  who,  if  fatigued  or  desirous  of  using  his 


22 


GYNECOLOGICAL    EXAMINATION. 


Lands  for  sponging  or  otlier  assistance,  may  place  the  knee  over  Lis  neck. 
In  tLis  position  tLe  sacrum  is  raised,  from  tLe  coucL,  tLe  body  rests  on  tLe 
upper  portion  of  tLe  sacrum,  tLe  sympLysis  is  greatly  elevated,  and  tLe 
promontory  correspondingly  depressed,  tLe  angle  between  tLe  two  being 
increased  to  fifty-five  or  sixty  degrees.  TLe  vagina  takes  an  almost  per- 
pendicular downward  course,  wLereby  tLe  cervix  is  more  easily  reacLed 
per  vaginam,  and  it,  and  tLe  wLole  posterior  surface  of  tLe  uterus  per  rec- 
tum. TLe  promontory  also  becomes  more  readily  accessible  to  tLe  vaginal 
finger,  a  fact  wortLy  of  remembrance  in  cases  of  prospective  obstetric  prog- 
nosis, wLen  tLe  lengtL  of  tLe  conjugate  diameter  is  to  be  measured.  TLe 
abdominal  walls  are  gTeatly  relaxed,  intra-abdominal  pressure  mucL  .di- 
minisLed,  and  palpation  tLerefore  facilitated.     Still,  care  sLould  be  taken 


Fig.  4.— Griuteo-dorsal  Position,  Front  View.     (Hegar  and  Kaltenbach.) 

not  to  elevate  tLe  tLorax,  or  overdo  tLe  pelvic  elevation,  as  tLe  crowding 
togetLer  of  tLe  abdominal  viscera  ■would  annul  tLe  gain  first  obtained.  TLe 
anterior  wall  of  tLe  vagina,  being  almost  pei-pendicular,  becomes  more 
readily  accessible,  even  up  to  tLe  cervix,  to  tLe  finger  and  eye,  a  discovery 
wLicL  Simon  utilized  for  tLe  operation  of  vesico-vaginal  fistula  wLicL  Le 
always  performed  in  tLis  position.  His  metLod  is  cLiefly  joractised  in  Ger- 
many, but  in  tLis  country  tLe  latero-abdominal  (Sims')  position  Las  an- 
swered all  tLe  desires  of  tLe  operator,  and  is  so  mucL  less  laborious  to  tLe 
assistants  tLat  it  is  scarcely  likely  to  be  superseded. 

Still,  tbere  are  cases  of  veiy  flesLy  women,  witL  large,  flabby,  or  cica- 
tricially  distorted  vaginae,  in  wLom  tLe  gluteo-dorsal  position  affords  a 
better  riew  of  tLe  field  of  operation  tLan  tLe  semiprone. 

As  a  rule,  it  is  well  to  remember  tbat  wLenever  a  difficulty  is  experi- 


LATERAL    POSITIOlsr.  23 

enced  in  reaching  the  cervix  or  other  pelvic  organ,  as  frequently  haj)pens 
when  the  patient  is  in  bed,  the  elevation  of  the  pelvis,  by  increasing  the 
flexion  of  the  thighs  on  the  abdomen  (i.e.,  by  directing  the  patient  to  shp 
farther  down  in  the  bed,  whereby  the  thoracic  elevation  is  also  diminished), 
or  by  putting  the  other  hand  or  a  cushion  under  the  sacrum,  will  at  once 
bring  the  desired  part  within  reach. 

Another  dorsal  position  has  recently  been  devised  by  Freund,  of  Stras- 
burg,  for  his  operation  of  abdominal  extirjoation  of  the  entire  cancerous 
uterus,  and  that  is  with  the  whole  pelvis  so  much  elevated  as  to  swing  fi-ee 
of  the  table,  the  knees  being  suspended  in  crutchlike  supports  fixed  in  the 
table  ;  the  body  resting  on  the  dorsal  and  cervical  vertebrae.  The  object 
of  this  position  is  to  gravitate  the  intestines  away  from  the  pelvis  and  thus 
freely  expose  that  cavity. 

For  examination,  I  can  imagine  that  it  might  be  utilized  for  palpation 
in  cases  of  small  pelvic  tumors  with  long  pedicles,  which  were  obscured  by 
the  superincumbent  intestines ;  and  also  for  the  removal  from  the  pelvic 
cavity  of  loose  ascitic  fluid  simulating  localized  effusion  or  tumors.  The 
stretching  of  the  vaginal  canal  in  this  position  would  render  it  unfit  for  a 
digital  examination. 

b.    Lateral  JPosition. 

The  lateral  position  may  be  either  right  or  left  in  accordance  with  the 
hand  chosen  for  the  examination.  The  left  side  is  the  one  generally 
adopted,  and  the  examination  is  made  with  the  right  hand.  Barnes  ad- 
vises using  the  left  hand,  which  to  me  appears  inconvenient  and  awkward. 
Were  I  to  use  my  left  hand  in  examining  on  the  side,  I  should  j)refer  to 
have  the  patient  on  her  right  side.  Examination  on  both  sides  may,  more- 
over, occasionally  be  useful. 

The  patient  lies  on  a  horizontal  plane,  her  head  supported  merely  by  a 
pillow  ;  the  hips  down  to  the  edge  of  the  table  ;  the  thighs  flexed  at  right 
angles  to  the  body ;  the  shoulders  and  hips  perpendicular  to  the  plane.  In 
this  position  the  pelvic  organs  maintain  very  much  the  same  relations  as 
on  the  back,  but  the  movable  abdominal  viscera  naturally  incline  toward 
the  dependent  side.  The  side  position  affords  facilities  for  exploring  the 
lateral  and  posterior  portions  of  the  pelvis  (the  right  half  of  the  pelvis 
being  more  accessible  to  the  right  index  finger,  on  the  left  side,  and  the 
reverse),  and  may  enable  the  examiner  to  detect  a  laterally  prolapsed 
ovary,  or  slight  perimetric  exiidation,  or  dislocated  coccyx,  which  escaj^ed 
his  observation  on  the  back.  The  lower  portion  of  the  rectum  may  also 
be  examined  by  eversion  from  the  vagina,  or  by  the  siDeculum. 

Although  bimanual  examination  is  jDOSsible  by  passing  the  external 
hand  between  the  thighs  of  the  patient,  it  is  obvious  that  it  can  neither 
be  so  convenient  nor  accurate  as  when  the  patient  is  on  her  back.  The 
reason  given  by  Barnes  for  preferring  the  left  hand  for  indagation  is  that 
the  right  hand  can  be  more  conveniently  (!)  used  for  simultaneous  abdomi- 
nal palpation.  The  palpation  of  small  abdominal  tumors  may  be  facilitated 
in  the  lateral  position,  by  permitting  the  isolation  of  the  tumor,  if  it  be 


24 


GYNECOLOGICAL    EXAMINATION. 


situated  on  the  uppermost  side,  or  its  grasping  between  the  fingers  of  one 
hand,  if  it  be  on  the  dependent  side.  Thus,  in  a  case  of  double  floating 
kidney,  in  a  parous  woman,  I  was  able  to  gTasp  readily  the  kidney  of  the 
uppermost  side,  as  it  was  extruded  by  voluntary  expiratory  pressure  from 
below  the  ribs,  when  in  the  dorsal  position  it  was  almost  impossible  to  iso- 
late the  organs.     It  is  also  useful  in  percussing  for  free  ascitic  fluid. 

For  the  ordinary  purposes  of  diagnosis  (except,  perhaps,  mere  local 
inspection),  the  straight  lateral  position,  in  my  opinion,  is  decidedly  infe- 
rior to  the  dorsal,  which,  moreover,  permits  the  use  of  either  hand  for 
indagation  without  change  of  position.  It  is  also  evident  that  whatever 
displacement  of  the  peMc  organs  possibly  occurs  on  the  side,  is  not  usual 
to  the  patient,  and  can  therefore  but  serve  to  confuse  the  diagnosis. 

Nevertheless,  the  majority  of  English  gynecologists  persist  in  using 
the  left  lateral  position,  both  for  indagation  and  examination  with  the 
cylindrical  and  bivalve  speculum. 

e.    Later o-abdominal  Position. 
Next  to  the  dorsal,  the  latero-abdominal,  or  semiprone,  position  is  un- 
questionably the  most  useful ;  not,  however,  for  a  digital  examination,  but 
for  the  employment  of  the  speculum,  and  chiefly  one  pariicular  speculum, 
the  duck-bill  of  Sims. 


Fig.  5.— Latero-abdominal  (Sims")  Position.     (Hegar  and  Kaltenbach.) 

A  digital  examination  can,  it  is  true,  be  performed,  and  the  other  varie- 
ties  of  specula  introduced  quite  as  successfully  (and  more  advantageously, 
as  will  be  shown  hereafter)  in  this  position  as  in  the  straight  lateral ;  but 
it  is  chiefly  for  the  exposure  of  the  whole  vaginal  tract  by  the  duck-bill 
that  this  position  is  useful. 

The  patient  lies  on  her  side  (right  or  left ;  the  left  is  the  one  usually 
employed,  and  is  recommended  by  the  discoverer  of  this  position,  Sims, 
because  the  nurse  can  best  hold  the  s^Deculum  with  her  right  hand),  on  a 


LATERO-ABDOMINAL    POSITION".  25 

perfectly  flat,  hard  table,  the  head  on  a  low  pillow,  the  lower  (we  will  take 
the  left)  shoulder  and  that  half  of  the  thorax  touching  the  table,  the  other 
shoulder  but  slightly  raised  from  it,  the  left  arm  thrown  out  behind  and 
hanging  over  the  edge  of  the  table  ;  the  left  hip  touching  the  lower  edge 
of  the  table,  the  right  hip  somewhat  to  the  left  in  coiTesj)ondence  with  the 
right  shoulder,  the  thighs  and  knees  flexed  at  right  angles,  the  right  knee 
slightly  overlapping  the  left,  the  feet  close  together,  projecting  over  the 
left  corner  of  the  table,  and  supported  by  the  back  of  a  chaii-  or  other  ar- 
ticle of  furniture.  In  this  position  the  woman  Hes  partly  on  her  side,  and 
partly  on  her  stomach,  the  abdominal  viscera  gravitate  forward  and  down- 
ward away  from  the  pelvic  cavity ;  the  pelvis  has  a  lateral  and  downward 
inclination,  so  that  a  line  drawn  from  the  coccj^  through  the  rima  \a1lv0e 
will  strike  the  left  popHteal  space.  The  posterior  vaginal  wall  is  thus 
superior  to  the  anterior,  and  the  uterus  sinks  downward  and  forward. 
Intra-abdominal  pressure  is,  to  a  great  extent,  suspended.  By  admitting 
air  into  the  vagina  in  this  position  a  counter-pressure  may  be  made  to  the 
intra-abdominal  pressure  ;  and  any  force  still  exerted  by  the  latter  will  be 
entirely  neutralized. 

For  ocular  examination  this  position  is  unrivalled,  and  for  instrumen- 
tal and  operative  measures  on  the  vagina  and  cervix  almost  indispensable. 
Whenever  Sims'  position  is  mentioned  in  this  work,  the  left  semiprone  po- 
sition is  intended.  While  a  hard  table,  merely  covered  with  a  blanket, 
or  tightly  upholstered,  is  undoubtedly  the  best  couch  for  this  position,  and 
the  examination  is  facilitated  by  giving  the  table  a  lateral  and  downward 
incHnation  toward  the  lower  side  and  head  of  the  patient,  a  tolerably  satis- 
factory examination  may  be  made  on  a  firm,  level  sofa,  or  bed,  which  does 
not  allow  the  hip  to  sink  in  to  the  level  of  the  vulva.  The  table  should  be 
so  placed  that  the  light  falls  directly  upon  the  vulva  over  the  right  shoulder 
of  the  operator  ;  the  table  will  therefore  occupy  a  diagonal  position  before 
the  window. 

d.   Abdominal  Position. 

This  position  is  useful  to  the  gynecologist  only  in  so  far  as  it  enables 
him  to  examine  the  spinal  column  and  the  posterior  aspect  of  the  pelvis, 
for  any  abnormalities  which  may  affect  the  diameters  of  the  pelvis  or  the 
position  of  the  internal  genital  organs. 

e.    Genupectoral  Position. 

The  patient  is  placed  on  a  hard,  level  couch,  her  head  so  ttuned  as  to 
rest  on  one  side  of  the  face  on  a  low  j)illow,  her  shoulders  and  upper  thorax 
directly  touching  the  couch,  her  thighs  at  right  angles  to  the  pehis,  the 
knees  and  hips  close  to  the  edge  of  the  table,  the  feet  slightly  projecting 
over  the  edge.  In  this  position  the  body  i^ests  on  the  upper  portion  of  the 
thorax  and  the  knees,  the  pelvis  being  very  much  higher  than  the  thorax. 

The  sacrum  is  then  the  highest  point,  its  anterior  surface  looks  down- 
ward and  forward,  the  symphysis  is  but  slightly  low^er  than  the  promon- 


26 


GYNECOLOGICAL    EXAMINATION. 


tory,  but  tlie  downward  inclination  of  the  lumbar  vertebral  column  is  a 
very  rapid  one.  The  anterior  wall  of  the  vagina  is  nearly  horizontal,  the 
cervix  uteri  points  toward  the  sacrum,  the  fundus  downward  and  forward 
following  the  general  dii-ection  of  all  the  jDehdc  and  abdominal  viscera. 
Intra-abdominal  pressui'e  is  entu'ely  suspended,  and  if  air  enters  the  vagina 
by  suction  (as  occurs  with  a  gaping  Aoilva),  or  is  allowed  to  enter  through 
a  speculum,  a  positive  counter-pressure  or  vis  a  tergo  is  added  to  the  vis  a 
fronte  of  gravitation.  The  vagina  becomes  elongated  by  the  traction  of 
the  anteverted  uterus,  and  if  air  enters  is  expanded  like  a  balloon  and 
every  part  becomes  readily  visible. 

For  purposes  of  digital  examination  this  position  is  obviously  unfitted 
through  the  elongation  of  the  vagina  already  mentioned.  It  is  mainly  use- 
ful as  a  means  of  replacing  a  dislocated,  chiefly,  retrodisplaced  uterus, 


Fig.  6. — Genupectoral  Position — Posterior  View.     (Hegar  and  Kaltenbach.) 

especially  if  the  fundus  has  become  impacted  in  the  sacral  excavation  and 
resists  digital  rejDlacement  on  the  side.  The  prolapsed  uterus  or  ovaries, 
and  small  incarcerated  fibroid  or  ovarian  tumors  with  long  pedicles,  are 
also  most  easily  replaced  in  this  position,  either  sj)ontaneously  or  b}^  man- 
ual pressure. 

To  determine  the  length  of  the  intravaginal  jDortion  of  the  cervix  this 
position  is  invaluable.  A  cervix  which  appears  greatly  elongated,  even 
to  the  ^a^lva,  will  be  no  longer  than  normal  when  examination  (sounding, 
indagation,  and  inspection)  is  made  in  the  knee-chest  jDOsition.  A  jDecu- 
liar,  microscopically  as  yet  unfathomed,  ductile  condition  of  the  uterus  is 
the  cause  of  this  phenomenon.  In  the  dorsal  or  erect  position  the  uterus 
draws  out  like  putty  ;  in  the  knee-chest  position  gravitation  causes  it  to 


GENU-PECTORAL    AND    ERECT    POSITIONS.  27 

shrink.     It  is  important  to  make  this  experiment  in  supposed  hypertrophic 
elongation  of  the  cei-vix  and  in  prolapsus  uteri. 

Pessaries  are  also  at  times  advantageously  applied  in  this  position,  and 
appHcations  of  fluids  made  to  the  distended  vagina.  For  operations  the 
position  is  not  generally  available,  as  it  is  too  uncomfortable  to  be  long 
borne,  and  the  administration  of  anesthetics  is  difficult,  if  not  impossible 

hi  it.  .... 

Palpation  is  rarely  attended  with  particular  advantage  in  this  position, 
since  the  weight  of  the  abdominal  walls  on  the  palpating  hand  materially 
interferes  with  the  perception  of  an  intra-abdominal  tumor.  Still,  .occa- 
sionally the  extent  and  manner  of  the  downward  displacement  of  the 
tumor  may  be  detected  by  palpation  and  afford  valuable  information. 

It  is  evident  that  the  genn-jjectoral  position  should  not  be  confounded 
with  its  incomplete  substitute,  the  genn-cubiial,  in  which  the  upper 
portion  of  the  body  rests  on  the  elbows  instead  of  the  thorax,  and  the 
downward  inclination  of  the  vertebral  column  is  very  sHght.  The  essen- 
tially beneficial  influences  of  the  former,  gravitation  and  suspension  of 
intra-abdominal  pressure  are  absent  in  the  latter,  and  the  genu-cubital 
position  is  useful  only  for  the  operation  of  certain  cases  of  vesico-vagmal 
fistula  which  are  not  readily  accessible  in  Sims'  position. 

f.   Erect  Position. 

In  the  pehis  of  a  woman  in  the  erect  position  the  most  dependent  por- 
tion is  the  symphysis  pubis,  even  the  tip  of  the  coccj^  being  sUghtly  higher 
than  the  inferior  border  of  the  arcus  pubis.  The  promontory  is  situated 
at  an  angle  of  55°  above  the  crest  of  the  symphysis.  The  vulva  points 
downward  and  very  slightly  foi-ward,  the  vagina  pursues  an  upward  and 
backward  direction  ;  the  anterior  vaginal  wall  is  the  first  to  meet  the  ex- 
amining finger,  the  uterus  has  descended  somewhat  in  the  pelvis,  the  cer- 
vix generally  backward,  the  fundus  more  than  usually  discernible  through 
the  anterior  vaginal  wall  (this  displacement  occui'S  more  markedly  m  par- 
ous women,  though  it  is  met  with,  to  a  shght  degree,  in  nulliparae)  ;  the 
anterior  abdominal  wall  is  tense  and  protrudes  in  the  convex  outhne.  In 
short,  in  accordance  with  the  law  of  gravitation,  involuntary  intra-abdom- 
inal pressure  is  increased  to  its  maximum.  Deformities  of  the  spinal 
column  (particularly  lordosis  and  kyphosis)  ;  excessive  obliquity  of  the 
pelvis,  whereby  the  promontoiy  and  symphysis  are  placed  almost  in  a  per- 
pendicular Hne  ;  relaxation  or  diastasis  of  the  abdominal  muscles,  abdom- 
inal tumors,  displacement  of  the  uterus  or  vagina,  will,  of  course,  alter 
more  or  less  the  above  relations. 

Since  the  symptoms  complained  of  by  women  suffering  with  utenne 
disease  are  usually  most  intense,  while  the  patients  are  on  their  feet,  walk- 
ing or  standing,  it  is  self-evident  how  important  it  is  to  ascertain  the  con- 
dition of  the  presumably  diseased  organs  in  that  position.  A  digital  (and 
even  ocular)  examination  of  the  genitals  is  therefore  important  in  many 
cases,  particularly  displacements,  in  order  to  ascertain  the  actual  amount 


28 


GYNECOLOGICAL    EXAMIlSrATIO]!^. 


of  displacement  during  standing,  or  the  amount  of  support  given  by  a 
pessaiy  with  the  superincumbent  weight  of  the  abdominal  viscera  pressing 
upon  it ;  or  the  persistence  of  the  dislocation  found  in  the  recumbent  posi- 
tion. Thus  a  retroversion  on  the  back  may  be  found  an  anteversion  or 
simple  descensus  on  the  feet.  I  have  repeatedly  detected  the  cause  of  a 
sensation  of  weight  and  pain  in  the  suprapubic  region  by  finding  the  cervix 
uteri  resting  on  the  pelvic  floor,  or  the  fundus  pressing  against  the  sym- 


FiG.  7.— Erect  Position.     (Hegai-  and  Kaltenbach.) 

physis,  while  examining  in  the  erect  posture,  when  previous  exploration  in 
the  dorsal  position  had  failed  to  reveal  any  displacement  or  other  cause  for 
the  symptoms  complained  of.  The  entire  relief  afforded  by  a  suitable  pes- 
sary showed  the  correctness  of  the  diagnosis,  which  could  not  have  been 
made  in  any  but  the  erect  posture.  Anj^  imaginary  objection  on  the  part 
of  the  patient  for  esthetic  reasons  is  readily  overcome  when  the  valuable 
information  to  be  obtained  by  this  examination  in  the  erect  posture  is  ex- 
plained to  her.  I  am  under  the  impression  that  digital  examination  in  this 
position  is  by  no  means  so  frequently  employed  as  it  should  be. 


4.  EXAMINATION  COUCHES. 

The  exigencies  of  practice  require  us  to  see  many  of  our  gynecological 
patients  at  their  homes,  and  to  examine  them  on  any  couch  which  happens 
to  be  convenient,  generally  a  sofa,  or  a  bed,  and  if  practicable  in  the  gluteo- 
dorsal  position,  with  the  hips  resting  on  the  edge  of  the  bed,  the  patient 
lying  crosswise,  in  which  case  it  is  well  to  place  a  lapboard  or  some  hard 
board  under  the  patient's  pelvis.     A  very  fair  examination  may  be  made, 


EXAMIISrATION-  COUCHES. 


29 


and  a  correct  diagnosis  arrived  at,  in  this  manner  ;  but  whenever  the  case 
presents  unusual  difficulties  of  diagnosis,  or  the  examination  entails  the 
use  of  the  duck-bill  speculum,  it  should  be  undertaken  on  a  proper  level 
table  or  high  couch,  with  all  the  necessary  conveniences  and  assistance. 
The  feebleness  of  the  patient  may  require  this  to  be  done  at  her  home  ; 


Pig.  8.— Goodeirs  Examining- table. 

but  the  physician  should  impress  upon  those  of  his  patients  who  are  able 
to  walk  the  advantage  to  himself  as  regards  convenience,  and  therefore  to 
themselves  as  regards  freedom  from  discomfort  and  pain,  of  having  the 
examination  made  at  his  office.  For  like  reasons  all  subsequent  treatment 
which  does  not  require 
rest  in  bed  should  also 
be  administered  at  the 
office. 

The  specialist  will  al- 
ways examine  his  office 
patients  on  a  table  pve- 
pared  for  the  purjjose, 
while  the  general  practi- 
tioner more  frequently 
makes  use  of  an  adjusta- 
ble examining-chair,  of 
which   there  are  various 

,. 11  11        1        1     1      •  Fig.  9. — Chadwick's  Examining  table. 

patterns,  the  best  being, 

in  my  estimation,  those  of  Archer  &  Wilson.  The  disadvantage  of  these 
chairs  is  that,  while  they  are  very  useful  for  digital,  bimanual,  and  ordinary 
specular  examinations,  their  immovable  side-arms  render  them  unfit  for 
the  use  of  the  duck-bill  speculum.  The  specialist,  therefore,  in  this 
country  at  least,  is  always  provided  with  an  office-table,  particularly  con- 
structed for  the  use  of  this  speculum,  without  which  modern  gynecology 
can  scarcely  be  efficiently  practised.  Any  ordinary  strong  level  table 
4'  by  2|-',  and  3'  high,  with  about  2"  of  the  legs  at  the  head-end  sawed  off, 


30 


GYITECOLOGICAL    EXAMINATION. 


will  do  for  this  purpose  ;  indeed,  in  case  of  need,  the  examination  can 
be  made  on  a  loauge  or  bed,  when,  however,  difficulty  is  generally  found 
in  securing  good  light,  and  the  lowness  of  the  couch  is  very  uncomfortable 

to  the  phj'sician.  The  specialist 
will  find  it  worth  his  while  to 
procure  the  best  possible  arrange- 
ment for  his  peculiar  practice, 
and  this  is  undoubtedly  a  firmly 
upholstered  table  of  the  follow- 
ing descrij)tion  :  It  is  42"  long, 
27"  wide,  32"  high  at  the  foot, 
29"  at  the  head,  sloping  three 
inches  from  foot  to  head.  It  has 
a  headpiece  and  sidepiece  to  pre- 
vent the  patient  from  sliding  off. 
The  table  has  a  double  top,  the 
upper  padded  one  being  capable 
of  being  raised  at  the  left  side 
of  the  table,  by  a  lever  to  a  height 
of  4",  the  right  border  moving 
on  hinges.  In  this  way  the  ab- 
domen gets,  besides  the  constant 
downward  dip  of  3"  built  into  the 
table,  an  optional  dip  of  4",  whereby  the  abdominal  viscera  are  still  further 
thrown  to  the  dependent  left  side  of  the  patient.     (This  movable  top  is 


Fig.   10. — Chadwick's   Examming-table  with  Patient  in 
Front  View. 


Flo.  11. — Chadwick's  Examining-table  with  Patient  in  Sims'  Position. 

not  absolutely  necessary,  and  some  expense  will  be  saved  by  omitting  it. 
I  have  not  had  occasion  to  use  it  for  some  years. )  At  the  foot-end  are  two 
sliding  boards,  the  left  one  provided  with  a  movable  padded  block  for  the 


EXAMINATION    COUCHES. 


31 


feet  to  rest  upon,  and,  with  the  block  tipped  down,  foi  the  left  foot  in 
examinations  on  the  back;  and  the  right  one  for  the  right  foot  in  the  same 
position.  These  shdes  have  sockets  cut  into  them  for  the  heels  of  the  pa- 
tient's shoes.  At  the  foot  of  the  table  is  a  long  drawer  for  instruments 
and  fluid-bottles  ;  at  the  head-end  any  desired  number  of  drawers  may  be 
attached,  arranged  to  suit  the  fancy  of  the  owner.  The  patient  mounts  on 
the  table  by  means  of  a  smaU  stepladder  or  footstool,  and  the  physician 
sits  at  the  foot-end  on  a  round  (piano-)  stool.  The  footstool  may  contain 
a  basin,  or  be  utilized  for  cotton,  tampons,  or  waste  scraps. 

The  table  which  I  have  here  described  is  one  used  by  Dr.  Goodell  and 
modified  after  one  of  Dr.  M.  D.  Mann,  who  had  the  idea  from  Dr.  T.  G. 
Thomas,  who  to  my  knowledge  was  the  first  to  have  a  table  of  this  pattern 
constructed.  I  myself  had  one  made  after  Dr.  Thomas'  pattern,  with  a 
slight  difi'erence  in  the  arrangement  of  the  drawers,  and  have  used  it  con- 
stantly and  with  the  greatest  satisfaction  for  the  past  ten  years.  This  table 
can  be  made  by  any  ordinary  cabinetmaker  or  carpenter,  neatly  upholstered 
in  leather,  at  from  thirty  to  forty  dollars.  A  cheaper  and  less  elaborate 
table  of  this  pattern  is  that  of  Dr.  S.  W.  Francis,  of  Newport,  E.  I.  To 
each  top  are  attached  two  serrated  arms,  by  which  the  tops  can  be  raised 
as  high  as  the  arms  will  permit,  being  prevented  from  faUing  by  ratchets 
which  catch  under  the  teeth.  To  lower  either,  it  is  necessary  only  to  pull 
upon  the  handle,  which  is  attached  to  a  cord  connected  with  an  escape- 
ment on  that  side.  It  is  made  to  order  by  Caswell,  Hazard  &  Co.,  of  New 
York.  Another  very  practical  and  ornamental  examining-table  is  that  de- 
vised by  Dr.  James  E.  Chadwick,  of  Boston,  and  sold  by  Codman  &  Shurt- 
leff,  of  that  city,  for  forty -five  dollars.  The  accompanying  cuts  sufficiently 
explain  its  construction.  It  does  not  possess  the  lateral  and  longitudinal 
obliquity,  the  former  of  which  is  of  inestimable  value  in  enabhng  the  phy- 
sician to  dispense  with  the  services  of  a  nurse  to  hold  the  speculum  ;  the 
lateral  pitch  tips  the  viscera  so  far  forward  and  downward  that,  on  re- 
tracting the  perineum  with  the  speculum,  and  admitting  air  into  the  vag- 
ina, the  anterior  vaginal  wall  is  so  ballooned  out  as  to  render  a  depressor 
unnecessary  ;  the  physician  therefore  has  his  right  hand  free  for  other 
work. 

The  objection  has  been  made  against  these  tables  that  their  appearance 
is  alarming  and  repulsive  to  the  patient,  who  hesitates  to  mount  on  a  table 
which  looks  to  many  of  them  hke  wliat  one  of  my  patients  delights  in  call- 
ing it,  a  "  rack."  Besides,  it  is  objected  that  they  are  not  as  neat-looking 
as  an  adjustable  chair,  and  show  what  they  are  intended  for.  As  regards 
the  latter  objection,  it  may  be  answered  that  the  office  of  a  i^hysician  is 
not  a  lady's  boudoir ;  and  as  for  a  lady's  refusing  to  mount  the  table,  I 
have  never  found  more  than  a  momentary  hesitation  on  being  confronted 
with  it  behind  the  screen,  with  which  most  gynecologists  hide  their  instru- 
ments of  torture  ;  and  I  am  quite  confident  that  no  woman,  however  re- 
fined or  capricious,  will  care  whether  it  is  a  table  or  a  chair  on  which  she 
has  to  place  herself,  at  the  request  of  her  trusted  physician,  when  once  she 
has  made  up  her  mind  to  an  examination.    Of  course,  the  physician  can  do 


32  GYNECOLOGICAL    EXAMINATION. 

much  by  his  manner  (as  already  stated)  to  mitigate  the  unpleasantness  of 
the  ordeal. 

For  operations  an  ordinary  flat  table  of  the  size  first  mentioned,  covered 
by  a  quilt  and  sheet,  answers  every  purpose. 


5.   EXAMINATION  WITHOUT  INSTRUMENTS. 

A.   Inspection. 

When  a  gynecological  patient  presents  herself  for  diagnosis  and  treat- 
ment, it  is  incumbent  on  us,  after  taking  her* general  history  and  symp- 
toms, to  ascertain  what  information  ocular  inspection — general  and  local 

of  her  person  will  give  us. 

A  glance  at  her  figui-e  will  tell  us  whether  she  is  tall  or  short,  lean  or 
stout,  well-built  or  misshapen.  The  expression  and  color  of  her  face  will 
show  whether  she  is  in  apparently  good  general  health,  or  whether  she  is 
anemic  (chlorotic),  plethoric,  or  cachectic  ;  the  expression  of  her  eyes,  and 
her  manners,  may  tell  us  her  peculiar  temperament.  Her  tongue  and 
gums  will  inform  us  to  some  extent  of  the  condition  of  her  digestive  or- 
gans and  the  quality  of  her  blood.  Even  through  the  clothes  we  can  de- 
tect any  unusual  prominence  of  the  abdomen ;  and  it  may  be  useful  to 
note  the  amount  of  her  mammary  development. 

On  placing  the  patient  in  the  dorsal  position,  if  there  be  anything  in 
the  symptoms  calling  for  an  inspection  of  the  breasts  and  abdomen,  the 
clothing  is  loosened  about  the  waist,  and  the  abdomen  laid  bare,  the  flexed 
lower  extremities  being  covered  by  a  sheet,  as  well  as  the  face,  if  the  pa- 
tient desires  it.  The  breasts  are  then  exposed,  their  size  and  firmness,  the 
color  of  the  areolae  and  nipples,  presence  or  absence  of  the  small  glandular 
nodules,  known  as  Montgomerj^'s  foUicles  (the  unusual  development  of 
which  is,  unless  lactation  be  performed,  strong  evidence  of  pregnancy),  no- 
ticed. Proceeding  to  the  abdomen,  its  distention,  shape,  color  ;  the  'hue 
of  the  Imea  alba  ;  the  j)rominence  of  the  umbilicus ;  the  presence  or  ab- 
sence of  irregular  pink  or  white  striae,  and  of  a  separation  of  the  recti 
muscles,  are  all  signs  to  be  observed  by  the  eye.  Peculiar  motions  of  the 
abdominal  wall  due  to  the  movements  of  a  child  in  the  uterus,  or  the  peri- 
staltic action  of  the  distended  intestines,  or  contractions  of  the  abdominal 
muscles,  or  the  pulsations  of  the  abdominal  aorta,  may  also  be  visible  if 
the  walls  are  thin.  The  presence  of  the  striae  above-mentioned  was  for- 
merly attributed  to  laceration  of  the  corium  of  the  skin  by  its  distention ; 
recently  Dr.  Busey,  of  Washington,  has  advanced  the  view  that  they  are 
due  to  the  obliteration  of  lymph-spaces  and  atrophy  of  adipose  tissue  in 
the  corium.  They  by  no  means  j^rove  the  presence  or  previous  existence 
of  pregnancy  (for  they  are  wanting  in  ten  per  cent),  and  merely  show  the 
occurrence  of  a  certain  amoimt  of  distention  of  the  skin  from  any  cause  ; 
they  are  formd  not  only  on  the  skin  of  the  abdomen,  but  also  on  that  of 
the  breasts,  thighs,  and  gluteal  region,  in  women  with  strongly  developed 
adipose  tissue. 


iNSPECTio:rT.  33 

Lispection  of  the  abdomen  may  further  show  us,  by  the  peculiar  dis- 
coloration or  cicatrization  of  certain  portions,  whether  bhsters,  leeches, 
tincture  of  iodine,  hot  poultices,  or  cupping,  have  been  employed,  and  thus 
give  a  hint  as  to  previous  affections  of  the  patient.  The  distended  urinary 
bladder  may  also  be  visible. 

The  appearance  of  the  lower  limbs,  their  straightness,  the  presence 
of  varicose  veins,  or  signs  of  present  or  previous  disease,  is  also  worth  a 
glance. 

While  it  is  necessary  to  inspect  the  remainder  of  the  body  only  when 
the  history  renders  it  desirable  to  do  so,  it  is  always  advisable,  in  my  opin- 
ion, to  subject  the  external  genital  organs  of  every  female  who  comes  to 
us  for  disease  of  the  sexual  system  to  a  careful  ocular  examination  before 
proceeding  to  the  first  internal  examination.  The  practice  of  a  gynecol- 
ogist is  rarely  confined  to  women  of  the  higher  classes,  and  even  among 
them  unexpected  forms  of  disease  of  the  external  genitals  are  occasion- 
ally found ;  in  the  lower  classes,  the  physician  has  to  fear  the  presence  of 
specific  or  parasitic  contagion  (pedicuU  pubis),  which  it  is  his  duty  to  him- 
self to  guard  against.  Irrespective  of  this  precaution,  the  information 
obtained  by  an  inspection  of  the  vulva  and  vaginal  orifice  is  often  of  the 
greatest  importance. 

The  examination  may  be  made  in  the  dorsal  position,  the  .patient  being 
covered  by  a  sheet,  or  on  the  side.  I  have  never  found  a  patient  object, 
provided  the  mistake  was  not  made  to  ask  her  permission.  If  the  inspec- 
tion is  made  as  a  matter  of  course  in  a  quiet,  deliqate  manner,  it  is  com- 
pleted almost  before  the  patient  is  aware  of  it. 

The  points  to  notice  are  :  the  situation  of  the  vulva,  whether  normal  or 
too  far  back  ;  the  color  and  size  of  the  labia ;  the  condition  of  the  mons 
veneris  (absence  of  pedicuh)  ;  the  presence  of  intertrigo  of  the  thighs  ;  the 
length  of  the  perineum  ;  the  presence  of  hemorrhoids  ;  the  co-adaptation 
of  the  labia,  or  gaping  of  the  vulvar  orifice  ;  the  size  of  the  clitoris  ;  the 
presence  of  ulcers  or  eruptions  (follicular,  chancroid,  or  hard  chancre, 
mucous  patches,  or  epithelioma)  on  the  vulva  or  perineum  ;  the  protrusion 
of  a  portion  of  the  vaginal  wall  ;  the  presence  of  varicose  veins,  or  edema  of 
the  labia.  On  gently  separating  the  labia  with  the  fingers  of  either  hand, 
the  introitus  vaginae  is  exposed  to  view,  and  its  color,  whether  normal,  pale 
pink,  or  red,  eroded,  and  inflamed  ;  the  presence  of  a  prolapse  of  the  ante- 
rior or  posterior  wall  of  the  vagina  ;  the  presence,  shape,  or  absence  of  the 
hymen  ;  the  evidence  of  coition  or  parturition  (lacerated  hymen  for  coition ; 
effacement  of  the  shreds  of  the  hymen,  rupture  of  the  fourchette  for  par- 
turition) ;  presence  and  character  of  the  vaginal  discharge  ;  swelhng  of  or 
discharge  from  the  Barthohnian  glands ;  the  appearance  of  the  meatus 
urinarius  ;  presence  of  caruncles — are  all  visible.  In  women  whose  wdvo- 
vaginal  tissues  have  become  relaxed  from  imperfect  puerperal  involution 
or  pluriparity,  the  vulva  frequently  gapes  so  much  as  to  afford  a  xiesv  some 
distance  into  the  vagina  on  merely  separating  the  labia  Avith  the  fingers, 
and  I  have  even  exposed  the  cervix  in  this  manner.  In  such  cases  the 
mere  spreading  open  of  the  thighs,  in  the  dorsal  position,  causes  the  vulva 
3 


34  GYNECOLOGICAL    EXAMIITATIOlSr. 

to  gape.  Occasionally  inspection  will  reveal  to  us  a  prolapsus  uteri  or  va^ 
ginse,  or  a  hernia  of  which  the  patient  had  made  no  mention. 

The  imjDortance  of  recognizing  by  a  local  examination  whether  a 
woman  is  a  virgin,  a  nullipara,  or  a  parous  woman  was  made  apparent  to 
me  in  two  cases  which  came  under  my  notice  during  the  past  two  years. 
In  one  a  young  woman  carrying  a  ten- months'  old  child  consulted  me  as 
to  whether  she  was  agaiia  pregnant,  saying  that  the  child  with  her  was 
hers  and  one  of  twins.  On  inspecting  her  vulva  I  found  the  hymen  torn, 
but  its  folds  still  present,  the  fourchette  intact,  and,  on  touching  the  cer- 
vix, a  smooth,  circular  os.  I  told  her  that  she  was  not  only  not  pregnant, 
but  that  she  had  never  had  a  child.  She  persisted  in  her  story,  and  I  dis- 
missed her.  A  year  later  she  came  again  to  see  whether  she  was  pregnant, 
and  this  time  I  found  her  so.  On  inquiring  her  motive  for  attemjDting  to 
deceive  me  previously,  she  said  that  I  was  quite  right,  but  that  she  had 
wished  to  fasten  the  paternity  of  a  child  on  her  lover.  In  the  second  case, 
an  elderly  maiden  lady  of  the  highest  resjDectability  consulted  me  for  some 
pelvic  ailment.  She  readily  consented  to  an  examination,  and  I  expected 
unusual  difficulty  in  inserting  my  finger.  What  was  my  surprise,  not  only 
not  to  find  a  tense  hymen  or  a  contracted  vaginal  orifice,  but  to  feel  my 
finger  shp  into  a  vagina  as  gaping  as  that  of  a  multipara,  and  on  inspection 
I  found  absolutely  no  vestige  of  the  hymen,  the  fourchette  gone,  and  the 
perineum  and  vulvar  aperture  presenting  every  trace  of  parturition.  I 
have  no  doubt  whatever  that  this  lady  had  given  birth  to  one  or  more 
children,  a  belief  which  is  confirmed  by  the  stanch  fidelity  which  she  has 
shown  me  since,  in  sjDite  of  my  suggesting  to  her  (as  a  safeguard  against 
allowing  her  to  suppose  that  I  had  overlooked  this,  for  a  virgin,  peculiar 
condition)  that  she  had  concealed  her  previous  marriage  and  maternity 
from  me,  a  suggestion  which  she,  of  course,  strenuously  denied. 

Two  small  tubular  glands  in  the  urethra,  which  open  at  either  side  of 
the  meatus,  have  lately  been  discovered  by  Dr.  Skene.  If  inflamed  they 
give  rise  to  a  very  obstinate  urethral  discharge,  which  can  be  cured  only 
by  slitting  up  the  tubules  and  cauterizing  them.  In  this  condition  their 
orifices  are  to  be  seen  as  two  minute  yellow  spots  at  either  side  of  the 
meatus. 

An  inspection  of  the  secretions  oozing  from  the  vagina,  or  removed  on 
the  examining  finger,  is  of  great  importance,  and  may  reveal  the  nature  of 
the  disease.  The  secretions  from  the  vaginal  and  the  endotrachelean 
mucous  membranes  differ  essentially  in  character  and  appearance  ;  the 
vaginal  being  creamy,  thin,  or  purulent,  and  of  acid  odor  ;  that  from  the 
cei-vix  thick,  stringy,  glairj',  or  discolored,  and  inodorous.  A  creamy 
vaginal  'discharge  is  usually  a  chronic  symptom,  and  depends  on  venous 
hypei'emia  or  general  anemia  ;  yellow,  greenish,  sanious,  offensive  discharge 
leads  to  the  susjDicion  of  an  acute  hyjDeremia  or  venereal  infection  ;  a  putrid, 
shreddy  secretion  speaks  for  malignant  disease.  The  expulsion  of  clots, 
so  often  spoken  of  by  patients  as  a  matter  of  importance  in  describing  the 
character  of  their  menstrual  discharge,  means  merely  the  retention  of  the 
blood  in  the  vagina  until  it  had  time  to  coagulate,  and  is  a  symptom  of  no 


AUSCULTATIOISr    AND    PERCUSSION.  35 

special  significance  whatever.  The  physician  should  always  be  cautious 
about  diagnosing  a  venereal  infection — a  gonon-hea — merely  from  the 
character  of  the  discharge.  He  should  remember  that  his  decision  impli- 
cates another  besides  his  patient,  and  that  he  may  be  called  upon  to  prove 
the  correctness  of  his  view  in  a  court  of  law. 


B.    Auscultation  and  Percussion. 

It  is  manifest  that  auscultation  can  but  rarely  be  of  service  to  us  in 
gynecological  practice.  But,  as  many  cases  of  pregnancy  come  into  the 
hands  of  the  gynecologist  for  diagnosis  of  that  condition,  it  is  obvious  that 
abdominal  auscultation  should  never  be  omitted  when  there  is  the  least 
prospect  of  the  patient's  being  in  advanced  pregnancy.  But  there  are 
other  conditions  in  which  auscultation  may  be  useful ;  such  as  tumors, 
in  which  the  ear  may  detect  the  presence  of  large  arteries  b}^  the  systolic 
thrill  spreading  from,  or  the  murmur  occurring  in  them  ;  or  the  existence 
of  peritoneal  roughness  and  adhesions  by  a  friction  sound ;  or  the  jDres- 
ence  of  an  aneurism  ;  or  the  presence  of  loose  ascitic  fluid,  by  its  splash- 
ing sound  on  sudden  change  of  position  of  the  patient.  In  suppurating 
ovarian  cysts  with  decomposed  contents,  the  presence  of  air  in  the  sac 
may  be  detected  by  a  succussion  sound.  The  pulsations  of  the  abdominal 
aorta  are  readily  audible,  and  may  be  distinguished  from  the  fetal  heart  by 
being  synchronous  with  the  radial  pulse. 

Percussion  has  a  far  wider  range  of  utiHty  ;  indeed,  it  is  indispensable 
in  the  diagnosis  of  abdominal  tumors.  As  for  auscultation,  the  jDatient 
should  be  in  the  recumbent  dorsal  position,  with  thighs  flexed,  the  cloth- 
ing about  the  waist  loosened  and  drawn  down,  and  the  abdomen  bared. 
By  means  of  percussion,  the  extent  of  a  tumor  may  be  detected  by  its 
area  of  dulness  ;  or  the  interposition  of  intestines  between  the  tumor  and 
abdominal  wall,  evidently  of  great  importance  during  ovariotomy,  and 
also  valuable  as  a  means  of  diagnosis  between  ovarian  tumors  (in  which 
the  uniform  dulness  shows  that  the  intestines  have  been  pushed  to  the 
sides  and  behind  the  tumor),  and  renal  or  splenic  growths  (in  which  in- 
testinal tympanitic  sound  is  usually  found  at  some  spot  of  the  anterior 
abdominal  wall).  Besides,  for  tumors  of  the  uterus  and  ovaries,  percussion 
is  useful  in  locating  and  defining  plastic  exudations  into  the  ceUular  tis- 
sue of  the  broad  ligaments,  and  into  the  peritoneal  cavity.  A  change  in 
quality  of  the  percussion  sound  on  altering  the  position  of  the  joatient 
will  show  the  presence  of  a  movable  mass  or  free  fluid  in  the  abdominal 
cavity. 

Percussion  is  applicable  directly  to  the  genital  organs  only  in  case  of 
vaginal  enterocele,  labial  hernia,  or  the  susi^icion  of  the  presence  of  intes- 
tines in  a  prolapsed  uterus  and  vagina. 

Auscultation  may  be  practised  either  with  the  stethoscope  or  directly 
by  placing  the  ear  to  the  abdomen  ;  percussion  may  likewise  be  made  with 
the  plessimeter  or  the  fingers.  Habit  and  preference  will  decide  in  favor 
of  either.     I  usually  j)i'efer  the  direct  methods. 


36 


GYNECOLOGICAL    EXAMINATIOJST. 


C.   Abdominal  Palpation. 

Palpation  is  by  far  the  most  important  method  of  examining  abdominal 
tumors,  very  many  of  which  without  it  would  practically  be  unrecogniza- 
ble. It  requires  a  great  amount  of  exercise  and  practice,  and  even  most 
competent  operators  have  been  misled  by  their  sense  of  touch  in  diagnos- 
ing abdominal  tumors.  The  differential  diagnosis  between  multilocular 
ovarian  cysts  and  fibrocysts  of  the  uterus,  for  instance,  is  often  absolutely 
impossible,  and  a  pregnant  uterus  has  been  taken  for  either  of  these  tu- 
mors, or  ascites  mistaken  for  an  ovarian  cyst  by  physicians  of  the  highest 
eminence. 

Of  course,  it  is  not  necessary  to  palpate  every  case  of  genital  disease. 
In  such  cases  in  which  it  aj)pears  desirable,  the  patient  should  be  placed  in 


Fig.  12. — Manner  of  using  Hands  in  Abdominal  Palpation.     (From  Mund^'s  "  Obstetric  Palpation.") 

the  dorsal  position,  which  will  produce  the  gTeatest  possible  relaxation  of 
the  abdominal  walls  and  the  minimum  of  intra-abominal  pressure.  Such 
a  position  would  be  that  described  as  the  gluteo-dorsal ;  but  as  this  posi- 
tion is  uncomfortable  and  unpleasant  to  the  jDatient,  it  is  advisable  to  try 
the  ordinary  flat  dorsal  position  with  sharply  flexed  and  but  slightly  sepa- 
rated thighs  first.  The  clothes  should  be  drawn  down  to  the  symphysis,  and 
the  abdomen  completely  bared,  as  in  inspection,  auscultation,  and  percus- 
sion, which,  indeed,  should  generally  precede  palpation.  There  are  other 
positions  in  which  palpation  is  practicable,  such  as  the  erect,  lateral,  genu- 
pectoral,  but  they  are  used  chiefly  to  ascertain  the  mobility  or  change  of 
position  of  a  tumor,  and  are  attended  with  the  difficulties  which  the  in- 
creased abdominal  pressure  entails  in  the  erect  posture,  and  the  weight  of 
the   abdominal  avails  and  viscera  in  the  genu-pectoral  position.     In  some 


ABDOMINAL    PALPATIOIST.  37 

instances  the  latter  proves  useful  in  dislodging  a  tumor  or  tlie  uterus  from 
the  pelvic  brim,  and  making  it  accessible  to  the  palpating  hand. 

The  patient  being  prepared  in  the  ordinary  dorsal  position  with  re- 
cently evacuated  bladder  and  rectum,  the  physician  steps  to  her  side  and 
places  his  warmed  hands  gently  on  the  abdomen,  using  only  the  tips  of 
the  four  fingers  for  palpation.  Proceeding  with  a  pawing  motion  he  ex- 
plores region  after  region  of  the  abdomen,  preferably  following  a  regular 
routine  in  order  not  to  overlook  any  portion.  Thus  he  may  first  palpate 
the  supra-umbilical  portion,  then  proceed  to  the  umbilical,  h}-pogastric, 
and  the  inguino-ovarian  regions.  The  supra-umbilical  portions  are  pal- 
pated with  the  finger-tips  pointing  upward,  the  median  parts  with  the 
finger-tips  pressing  backward  toward  the  vertebral  column,  and  the  infra- 
umbilical  regions  with  the  tips  pointing  downward  into  the  pelvic  cavity. 
Thus  region  after  region  is  explored,  and  any  abnormality  carefully  mapped 
out  and°traced.  A  great  obstacle  to  palpation  is  the  voluntary  resistance 
of  the  patient  by  contraction  of  her  abdominal  muscles.  This  may  be  over- 
come by  diverting  the  patient's  attention,  letting  her  open  her  mouth,  or 
take  a  deep  inspiration  and  make  a  correspondingly  long  expiration,  dur- 
ing which  latter  the  abdominal  viscera  and  wall  follow  the  receding  dia- 
phragm, and  the  fingers  can  be  rapidly  thrust  inward.  FiUing  the  bladder 
and  rectum  with  water  and  rapidly  withdrawing  it  will,  according  to  Hegar 
and  Kaltenbach,  produce  immediate  relaxation  of  the  abdominal  walls.  In 
cases  of  absolute  impossibility  to  secure  relaxation,  palpation  under  anes- 
thesia may  become  necessary,  unless  the  physician  would  run  the  risk  of 
making  an  utterly  wrong  diagnosis.  Tumors  of  apparently  undoubted 
existence  often  miraculously  disappear  under  an  anesthetic.  Thus,  I  re- 
member a  consultation  case  of  sui^posed  extra-uterine  fetation  with  appar- 
ently distinct  lateral  tumor  (the  uterus  being  found  normal  per  vaginam) 
in  an  excessively  hyperesthetic  patient,  where  the  tumor  had  entirely  dis- 
appeared when  the  examination  was  repeated  under  ether.  Patients  differ 
very  greatly  in  their  amenability  to  palpation;  in  nervous,  hysterical 
women  and  young  girls  the  practice  will  generally  be  found  very  difficult, 
often  impossible,  for  frequently  they  are  absolutely  incapable  of  control- 
ling their  will. 

Another  obstacle  of  scarcely  less  frequency  is  adiposity  of  the  abdomi- 
nal wall.  This  naturally  cannot  be  overcome.  Another,  still,  is  tender- 
ness and  inflammation  of  the  abdominal  or  pelvic  \iscera,  the  former  of 
which  may  often  be  annulled  by  gentleness  and  persuasion.  Another  is 
the  existence  of  free  fluid  in  the  abdominal  cavity,  which  may  requii-e 
removal"  before  palpation  is  practicable. 

Irrespective  of  the  advantage  of  gentleness  in  palpation  as  regards  the 
avoidance  of  exciting  reflex  or  voluntary  abdominal  contractions,  or  pro- 
ducing pain,  it  is  advisable  to  use  great  caution  in  palpating  the  abdomen 
in  order  to  avoid  bruising  dehcate  or  inflamed  stiiictures,  tearing  ad- 
hesions, or  ruptui'ing  cysts.  The  latter  has  repeatedly  been  done  in  the 
case  of  small  ovarian  cysts. 

In  a  favorable  case  with  thin,  flaccid  abdominal  walls,  the  palpating 


38  GYNECOLOGICAL    EXAMINATIOIN'. 

fingers  can  readily  touch  the  lumbar  vertebrae,  the  sacral  promontory,  the 
abdominal  aorta,  the  pelvic  brim,  and  the  fundus  uteri.  The  presence  of 
a  tumor  or  swelling  of  any  kind  in  the  regions  named  would,  therefore, 
be  easily  detected.  Besides,  the  inguinal  regions,  the  crural  and  inguinal 
canals  should  be  palpated  for  enlarged  glands  or  hernial  sacs.  But  in  the 
majority  of  cases  the  fingers  can  only  enter  deeply  enough  to  feel  the  in- 
distinct resistance  offered  by  the  intestines,  and  can  but  suspect  the  fun- 
dus uteri  by  its  greater  firmness.  It  is,  therefore,  not  so  much  for  the 
detection  of  small  intrapelvic  growths  that  palpation  is  useful,  as  for  the 
recognition  and  tracing  out  of  large  tumors,  arising  either  from  the  uterus, 
ovaries,  kidneys,  liver,  spleen,  or  other  abdominal  viscera. 

There  are  several  normal  conditions  which  on  sujDerficial  observation 
might  easily  be  mistaken  for  pathological  growths.  Such  are  first  of  all 
the  pregnant  utems  ;  then,  the  distended  urinary  bladder ;  further,  the 
overloaded  intestine.  So  long  as  the  fetus  has  not  attained  a  palpable  size, 
the  existence  of  pregnancy  can  be  detected  by  palpation  only  by  the  ra- 
tional signs  and  the  uniform  spherical  enlargement  and  elastic  feel  of  the 
uterus.  When  once  the  separate  members  of  the  fetus  are  recognizable  by 
the  abdominal  touch,  the  differentiation  of  pregnancy  is  evidently  easy. 

There  are,  however,  cases  in  which  differentiation  is  exceedingly  diffi- 
cult ;  and  competent  observers,  even  of  the  highest  rank,  have  repeatedly 
mistaken  a  pregnant  uterus  for  an  ovarian  tumor,  or  have  overlooked  the 
coexistence  of  both  conditions.  Only  experience  and  careful  attention  to 
the  details  of  examination  will  guard  against  such  errors. 

The  distended  bladder  can  scarcely  be  overlooked  if  the  precaution, 
always  to  be  taken  before  proceeding  to  palpation,  of  securing  voluntary 
or  instrumental  micturition  immediately  beforehand  is  adhered  to.  The 
dull  percussion  sound,  central  situation,  uniform  ovoid  outline,  and  ab- 
sence of  depression  between  the  tumor  and  the  symphysis,  should  direct 
attention  to  the  bladder.  I  once  saw  a  case  in  which  such  a  central,  ovoid, 
tense  tumor,  of  the  size  of  an  adult  head,  appeared  quite  suddenly  above 
the  pubis,  and,  the  catheter  showing  the  absence  of  urine  in  the  bladder, 
the  diagnosis  remained  doubtful,  tintil  the  discharge  of  a  large  quantity 
of  fetid  pus  per  rectum,  and  disappearance  of  the  tumor,  showed  it  to  be 
one  of  those  rare  cases  of  perityphlitic  abscess,  in  which  the  pus  j)oints 
downward  and  toward  the  median  line. 

An  accumulation  of  fecal  matter  in  the  large  intestine  if  small  in 
amount  will  escape  detection  by  palpation,  unless  the  abdominal  walls  are 
very  thin  and  lax.  If  the  accumulation  increases,  it  may  be  recognized 
at  first  as  a  soft,  pultaceous,  displaceable  mass  of  greater  or  lesser  mag- 
nitude, later  as  hard  nodules  or  lumps.  If  situated  in  the  sigmoid  flexure, 
the  mass  might  be  taken  for  a  coil  of  intestines  matted  together  by  peri- 
tonitic  exudation,  particularly  if  there  be  tenderness  in  the  left  iliac  region. 
Occasionally  the  coprostasis  attains  such  dimensions  as  to  be  mistaken  for 
a  semisolid  ovarian  tumor,  as  happened  in  a  case  in  the  Julius  Hospital  in 
"Wurzburg  during  my  ser\dce  at  the  Maternity  there,  in  another  in  the 
practice  of  Dr.  Sears,  of  New  York,  and  in  a  thii-d  case  in  the  service  of 


ABDOMINAL    PALPATION.  39 

Dr.  J.  B.  Hunter  at  the  New  York  Woman's  Hospital.  The  free  evacua- 
tion of  the  bowels  would  obviously  clear  up  the  case  at  once,  but  unfortu- 
nately in  these  cases  of  coprostasis  that  is  precisely  the  most  difi&cult  thing 
to  obtain. 

Tumors  situated  in  the  anterior  abdominal  wall  between  the  sheath 
of  the  muscles  and  the  peritoneum  are  distinguished  with  the  greatest 
difficulty  from  intraperitoneal  growths.  Only  by  the  j)Ossibihty  of  making 
the  fingers  of  each  hand  meet  behind  the  tumor  can  its  extraperitoneal 
origin  be  assured.  Plastic  exudations  in  the  subperitoneal  cellular  tis- 
sue in  either  iliac  fossa  are  very  easily  accessible  to  palpation  and  percus- 
sion, which  would  not  be  the  case  if  the  exudation  were  in  the  true  pelvis. 
Eetroperitoneal  tumors  may  be  palpated  from  the  side,  or  by  grasping  the 
whole  lumbar  i*egion  of  one  side  in  one  or  both  hands ;  if  the  abdominal 
tumor  is  movable  and  simulates  a  floating  kidney,  the  diagnosis  may  be 
affirmed  or  corrected  by  feeling  for  the  kidney  in  its  normal  position  in 
the  manner  indicated.  Eetroperitoneal  tumors  are  only  palpable  through 
the  anterior  abdominal  wall,  when  they  have  attained  considerable  size. 
As  a  rule,  it  may  be  assumed  that  tumoi-s  growing  from  the  jDehis  spread 
upward  and  remain  connected  with  their  place  of  origin  so  as  to  have 
no  interruption  in  their  continuity.  Per  contra,  tumors  growing  downward 
from  the  superior  abdominal  organs  (kidney,  spleen,  hver,  stomach)  gener- 
ally leave  a  sulcus  between  their  lower  border  and  the  symphysis  pubis, 
and  do  not  reach  down  into  the  ti'ue  pelvis  until  they  have  attained  enor- 
mous size.  Exceptions  to  this  mle  may  occur  in  comparatively  small  pel- 
vic tumors  with  long  thin  pedicles,  which  permit  the  growths  to  rise  out 
of  the  pelvis  to  the  extent  of  the  pedicle,  thus  leaving  a  depression  above 
the  symphysis  ;  and  in  supra-abdominal  tumors  with  long  pedicles,  which 
allow  their  descent  into  the  pelvis.  In  some  cases  the  laxity  of  the  ab- 
dominal walls  will  permit  the  fingers  of  both  hands  to  be  pressed  in  so 
deeply  as  almost  to  meet  behind  the  tumor,  and  clearly  feel  the  relations 
of  its  attachment.  In  one  such  case  (of  complete  diastasis  of  the  abdominal 
muscles)  the  covering  was  so  thin  as  to  show  the  tortuous  vessels  of  the 
tumor  through  the  skin  ;  the  fingers  could  distinctly  grasp  the  slender 
pedicle  underneath  the  tumor  and  feel  it  arising  from  beside  the  uterus, 
the  fundus  of  which  was  also  palpable.  A  diagnosis  of  cyst  of  the  left 
ovary  was  made  by  myself  and  other  g^^necologists,  but  the  operation 
proved  the  tumor  to  be  a  cyst  of  the  mesentery,  and  the  thin  pedicle  to 
have  been  small  intestine.  In  another  case  where  I  had  positively  diag- 
nosed a  multilocular  ovarian  cyst,  and  had  practised  electrolytic  punctm-e, 
with  the  result  of  contracting  and  solidifying  the  growth,  the  consequent 
separation  of  the  lower  border  of  the  tumor  from  the  symphysis  induced 
several  of  otu:  most  prominent  gynecologists;  to- pronounce  it  a  renal  or 
splenic  tumor,  but  not  ovarian.  The  operation,  performed  by  one  of  these 
gentlemen,  showed  an  almost  solid  tumor  of  the  ovary  of  the  size  of  an 
adult  head,  attached  by  a  long  pedicle  to  the  left  broad  ligament. 

The  peculiar  feel  of  the  surface  and  substance  of  a  tumor  to  the  pal- 
pating fingers  is  a  valuable  aid  in  diagnosing  its   nature  and   contents. 


4:0  GYNECOLOGICAL    EXAMINATIOlSr. 

Thus  we  hare  a  smooth,  uniform,  elastic  contour,  with  the  sensation  of  a 
wavy  motion  imj)arted  by  one  hand  striking  the  abdomen  on  one  side  to 
the  hand  on  the  other  side,  and  we  think  of  a  large  cyst  with  fluid  contents 
and  moderately  thin  walls  ;  or,  we  feel  a  hard,  dense,  nodular  mass,  with 
here  and  there  large  protuberances,  and  no  evidence  of  fluctuation,  and 
the  chances  seem  in  favor  of  subperitoneal  uterine  fibroid  ;  or,  we  feel  a 
doughy,  fleshy,  irregular  surface,  which  is  slightly  impressible  biit  scarcely 
elastic,  and  we  think  of  a  semi-solid  ovarian  tumor,  or  a  uterine  fibrocyst. 
The  degrees  of  firmness  and  softness  of  tumors  are  so  exceedingly  variable 
that  it  is  impossible  to  define  them  ;  besides,  the  sense  of  touch  differs  in 
different  individuals.  Only  long  practice  can  enable  a  correct  discrimina- 
tion between  the  more  delicate  shades  of  resistance  of  different  tissues. 
Between  the  two  extremes  of  the  pulpy  softness  of  a  half-filled  ovarian  cyst 
(after  tapping)  and  the  stony  hardness  of  a  calcified  fibroid  or  lithopedion, 
there  are  innumerable  degrees  of  consistence. 

A  sensation  of  gradual  hardening  on  palpation  suggests  the  presence 
of  contractile  muscular  fibre  (enlarged  uterus,  as  chiefly  in  pregnancy),  and 
thus  affords  an  aid  to  diagnosis. 

The  sensation  of  fluctuation  is  probably  the  most  difiicult  of  all  to 
recognize  in  doubtful  cases.  When  one  hand  strikes  or  pushes  one  side 
of  the  abdomen,  and  the  palm  of  the  other  hand  applied  to  the  other  side 
feels  a  distinct  impulse,  like  a  wave  of  fluid  striking  against  it,  there  can 
be  but  little  doubt  of  the  presence  of  fluid.  So,  also,  when  this  wave  is 
felt  at  a  certain  distance,  and  is  imperceptible  somewhat  farther  off,  can  we 
assume  the  presence  of  a  partition  or  septum  dividing  the  cyst  into  two  or 
more  compartments.  But  to  detect  the  presence  of  deep-seated  fluid  in  an 
abdominal  tumor,  by  the  sensation  of  fluctuation,  requires  a  great  amount 
of  practice,  and  has  baflled  even  the  most  expert.  A  soft,  vascular,  succu- 
lent myoma  may  (like  a  subcutaneous  lipoma)  convey  a  precisely  similar 
impulse  to  that  of  fluid.  Errors  may  also  be  committed  by  mistaking  the 
elasticity  of  an  adipose  abdominal  wall  for  fluctuation. 

A  peculiar  boggy,  doughy  feel  of  a  tumor  may  suggest  deep-seated 
fluid,  but  a  positive  opinion  on  this  point  should  be  guarded. 

The  existence  of  fluid  having  been  determined  by  fluctuation,  it  is  im- 
portant to  ascertain  whether  this  fluid  is  enclosed  in  a  sac  or  is  loose  in 
the  peritoneal  cavity.  By  noting  the  absence  or  presence  of  changes  in 
the  seat  and  area  of  fluctuation  in  different  positions  of  the  patient,  this 
point  may  generally  be  settled.  Still,  I  have  seen  an  eminent  European 
surgeon,  assisted  by  a  no  less  eminent  gynecologist,  open  an  abdominal 
cavity  for  undoubted  ovarian  cyst,  and  find  only  free  ascitic  fluid.  This 
case  forcibly  illustrated  the  evil  of  making  a  careless  diagnosis  in  accord- 
ance with  a  preconceived  opinion. 

If  we  ra^jidly  press  in  the  abdominal  wall  and  then  as  quickly  relax  the 
pressure,  we  may,  in  certain  cases,  meet  with  a  sudden  momentary  resist- 
ance, like  that  of  a  solid  body  floating  in  fluid.  This  is  the  ballottement 
so  familiar  to  obstetricians  in  connection  with  the  movable  head  or  breech 
of  the  fetus  in  utero.     It  is  chiefly  met  with  in  gynecology  in  cases  of 


DIGITAL    EXAMIISrATION.  41 

pecliculated  subperitoneal  fibroids  of  the  uterus,  whicli  float  upon  the  in- 
testines as  in  water.  Small  solid  ovarian  tumors  may  give  the  same  sen- 
sation. I  recently  met  -with  a  case  in  my  service  at  Maternity  Hospital,  in 
which  a  pediculated  fibroid  at  the  fundus  uteri  was  mistaken  by  the  junior 
assistant  for  a  ballotting  fetal  head,  and,  as  one  head  presented  at  the  os, 
the  case  was  supposed  to  be  one  of  twins. 

The  thickness  of  the  fluid  may,  to  a  certain  extent,  be  estimated  by  the 
rapidity  and  distinctness  of  the  wave  of  fluctuation  ;  the  more  rapid  the 
wave,  the  thinner  the  fluid.  However,  the  tension  of  the  cyst  or  abdomi- 
nal wall  may  give  greater  impetus  to  the  wave,  and  thus  deceive  the  ex- 
aminer. 

A  change  of  position  of  the  patient  may,  by  altering  the  situation  and 
relations  of  the  tumor,  aid  in  settling  the  diagnosis.  Thus,  palpation  in 
the  side  or  knee-breast  position  may,  by  displacing  the  tumor  upward  and 
laterally,  give  access  to  its,  until  then,  obscure  attachments. 

Tenderness  of  the  abdominal  wall  is  a  great  obstacle  to  palpation,  and 
at  the  same  time  a  valuable  suggestion  as  to  the  diagnosis.  The  touching 
of  a  tender  spot  will  lead  us  to  examine  that  region  more  carefully,  and 
may  result  in  the  discovery  of  a  localized  peritonitis  or  cellulitis,  an  ovaritis 
or  a  hyperesthetic  uterus.  It  may,  also,  if  met  with  on  the  surface  of  a 
fibroid  or  ovarian  tumor,  lead  us  to  suspect  more  or  less  acute  peritonitis 
(therefore  future  adhesions)  at  that  spot. 

D.  Digital  Examination. 

The  introduction  of  the  finger — generally  the  index,  occasionally  also 
the  middle,  and  rarely  the  whole  hand — into  one  of  the  pelvic  apertures 
of  the  female,  vagina,  rectum,  and  (so  far  as  the  index  or  little  finger  alone 
are  concerned)  the  bladder,  enables  us  to  explore  the  cavity  of  the  true 
pelvis,  and  to  touch  certain  portions  of  the  organs  therein  contained.  If 
access  were  denied  us  to  these  cavities,  as,  for  instance,  in  cases  of  com- 
bined atresia  vaginae  and  rectal  stricture,  the  other  means  of  exploring 
the  pelvic  organs  already  described  would  manifestly  be  of  very  little  ser- 
vice. A  digital  examination  of  the  immovable  structures  of  the  pelvic 
cavity  (the  vagina,  rectum,  bladder,  cellular  tissue)  is  the  best  means  (ex- 
cepting only  the  eye)  of  exploring  these  parts  ;  but  so  far  as  the  movable 
pelvic  organs  (the  uterus,  ovaries,  tubes,  and  broad  ligaments)  are  con- 
cerned, the  intrapelvic  finger  alone  can  give  but  limited  information.  It 
touches  the  cervix,  perhaps  a  prolapsed  ovary  or  inflamed  broad  ligament, 
but  the  fundus  uteri  is  accessible  to  the  rectal  and  vaginal  touch  only 
when  displaced,  and  the  other  organs  can  be  but  vaguely  suspected.  Even 
the  finger  in  the  bladder  finds  movable,  floating  bodies  before  it  in  the 
fundus  uteri  and  the  ovaries.  Therefore,  an  essential  and  indispensable 
part  of  a  thorough  digital  examination  of  the  pelvic  organs  is  the  simul- 
taneous systematic  palpation  of  the  abdomen,  whereby  the  movable  or- 
gans are  steadied  and  crowded  down  against  the  internal  fingers.  Simple 
digital  examination  alone,  through  one  or  more  of  the  external  pehic  out- 


42  GYNECOLOGICAL    EXAMINATIOIST. 

lets,  is  admissible  only  when  there  is  a  counter-indication  to  palpation 
(tenderness,  or  joeritoneal  inflammation,  resistance  on  the  part  of  the  pa- 
tient, necessity  for  haste),  or  when  the  examination  is  merely  made  as  a 
supplement  to  previous  thorough  explorations. 

An  examination  may  be  made  simultaneously  with  different  fingers  of 
the  same  or  the  other  hand  through  the  vagina  and  rectum,  the  vagina  and 
bladder,  and  the  rectum  and  bladder. 

In  selecting  the  passage,  through  which  the  examination  is  to  be  made, 
two  mles  shovild  be  observed  :  1,  to  choose  the  canal  which  leads  most  di- 
rectly to  the  organ  to  be  examined,  and  through  which  the  latter  is  most 
accessible  ;  and  2,  to  select  that  passage  which  will  be  least  repugnant, 
painful,  or  dangerous  to  the  patient.  Of  the  three  canals,  the  vagina  is 
obviously  the  most  convenient  and  the  one,  through  its  constant  patency, 
best  fitted  by  nature  for  the  jDurpose.  The  examination  per  rectum  is 
always  repugnant  to  a  patient's  feelings,  certainly  not  pleasant  to  the  phy- 
sician (a  circumstance  not  to  be  considered,  however),  and  generally  more 
or  less  painful.  The  exploration  of  the  bladder  with  the  finger  requires 
previous  instrumental  dilatation  of  the  urethra,  and  should  therefore  be 
considered  in  the  hght  of  an  operation  to  be  practised  only  under  anes- 
thesia. Only  when  the  vaginal  exploration  fails  in  giving  the  desired  in- 
formation, should  the  rectal  touch  be  employed ;  and  not  until  these  two 
and  all  other  means  fail,  should  the  vesical  touch  be  resorted  to. 

Topographically,  the  cervix  uteri,  the  recto-  and  vesico-vaginal  septa, 
the  vaginal  roof,  and  the  para-uterine  cellular  tissue  are  best  felt  through 
the  vagina  ;  the  retro-uteiine  space,  Douglas'  pouch,  the  posterior  uterine 
sui'face,  the  sacral  excavation  and  the  sacro-ischiatic  notches,  through  the 
rectum  ;  and  the  ante-uterine  peritoneal  excavation  and  cellular  tissue, 
and  anterior  surface  and  fundus  of  the  utems  through  the  bladder.  The 
aid  of  simultaneous  abdominal  palpation  will,  however,  generally  enable  us 
to  dispense  ^^ith  a  vesical  examination  at  least. 

When  the  vagina  is  closed  to  the  finger,  a  combined  digital  examina- 
tion of  the  rectum  and  the  bladder  may  become  necessary,  and  has  given 
valuable  diagnostic  infonnation  in  congenital  atresia  of  the  vagina  and 
doubtful  presence  of  uterus  and  ovaries,  and  important  therapeutic  re- 
sults in  chronic  inversion  of  the  uterus. 

As  a  rule,  but  one  finger  should  be  employed  in  examining  the  pelvic 
passages  ;  occasionally,  if  the  vagina  is  very  long  or  capacious,  the  index 
and  middle  finger  may  be  introduced  ;  but  it  is  very  rarely  necessary  to 
insert  more  than  one  finger  into  the  rectum,  and  never  but  one  into  the 
bladder. 

a.    Vaginal  Touch. 

The  vaginal  touch  may  be  practised  either  in  the  erect,  the  dorsal,  or 
lateral  recumbent,  or  the  knee,  breast,  or  elbow  position.  Each  of  these 
positions  may  present  particular  advantages  for  indagation,  but  for  the 
large  majority  of  cases  the  dorsal  recumbent  is  the  most  convenient. 


DIGITAL    EXAMIN'ATIOISr.  43 

The  introduction  of  the  finger  into  the  vagina  naturally  presupposes 
the  patency  of  the  orifice  of  that  canaL  The  most  common  obstacle  to 
the  finger  is  the  hymen,  the  imperforation  of  which  requires  the  division 
of  the  septum  by  the  knife.  As  a  rule,  the  normal  aperture  of  the  hymen 
is  sufficiently  large,  and  the  membrane  so  elastic  as  to  permit  the  gentle, 
gradual  introduction  of  the  finger.  In  case  of  excessive  rigidity,  its  grad- 
ual dilatation  by  the  finger  at  the  risk  of  rupturing  it,  or  nicking  it  with 
the  knife,  are  justifiable  measures,  if  the  examination  is  imperative.  Not 
unfrequently  a  resistance  to  the  finger  may  arise  from  spasmodic  contrac- 
tion of  the  constrictor  muscle  of  the  introitus  vaginse,  due  either  to  fear, 
nervousness,  erosion  of  the  orifice,  or  reflex  spasm  (vaginismus)  ;  or  large 
flabby  nymphse,  tumors  of  the  labia  majora  or  clitoris,  excess  of  crinial 
development,  may  interfere  entirely  or  temporarily  with  indagation.  Or  a 
contraction  of  the  levator  ani  muscle,  or  excessive  rugosity  of  the  vagina, 
may  arrest  the  finger  after  it  has  passed  the  introitus. 

In  cases  where  the  obstacle  depends  on  the  voluntaiy  (although  unin- 
tentional) resistance  of  the  patient,  or  where  it  is  due  to  excessive  local 
irritability,  and  that  resistance  cannot  be  overcome  by  persuasion,  an  ex- 
amination under  anesthesia  is  necessary.  Occasionally  sufficient  local 
anesthesia  may  be  produced  by  vaginal  suppositories  containing  oj^ium 
and  belladonna,  or  iodoform,  to  enable  us  to  dispense  with  a  general  an- 
esthetic. 

The  previous  introduction  of  astringents  by  means  of  injections,  tam- 
pons, or  suppositories,  may  also  contract  the  vagina  so  much  as  tO  inter- 
fere with  indagation,  and  should  not  mislead  the  examiner  as  to  the  nature 
of  the  obstacle. 

As  a  rule,  a  vaginal  examination  should  give  no  absolute  pain.  Only 
in  pathological  conditions  (inflammation,  erosion,  ulceration,  hyperes- 
thesia, chronic  pelvic  infiltrations)  will  the  gentle  touching  of  the  vulvo- 
vaginal canal  and  its  surroundings  give  rise  to  pain.  Not  uncommon 
causes  of  pain  on  introducing  the  finger  are  caruncles  of  the  ui-inary 
meatus,  and  hyperesthetic  remains  of  the  hymen. 

The  physician  should  accustom  himself  to  examine  with  either  hand. 
The  patient  may  be  so  situated  in  bed  that  only  one  hand  is  available,  or 
one  hand  may  be  temporarily  disabled.  Besides,  certain  portions  of  the 
pelvis  are  more  readily  touched  with  one  index  than  the  other  ;  thus,  the 
left  side  of  the  pelvis  and  its  contents  are  more  easily  reached  with  the  left 
forefinger,  the  right  side  of  the  pelvis  and  its  contents  with  the  right. 

If  one  hand  is  to  have  the  preference  for  indagation,  it  should  decidedly 
be  the  left,  as  most  men  are  more  dexterous  with  the  right  hand  in  pal- 
pation, sounding,  and  other  instrumental  manipulations. 

The  index-finger,  in  the  vast  majority  of  cases,  suffices  perfectly  for 
indagation.  In  large,  patulous  vaginae,  or  where  it  is  desired  to  reach 
very  high,  the  middle  finger  may  also  be  introduced,  but  I  think  the  fan- 
cied advantage  of  higher  reach  is  counterbalanced  by  the  confusion  of  the 
tactile  sense  of  the  two  fingers,  and  the  discomfort  to  the  patient.  It  is 
rare  that  a  forefinger  is  physically  too  short  to  enable  it.  alone  to  make  a 


44 


GYNECOLOGICAL    EXAMIISTATIOIST. 


tliorougli  vaginal  examination  ;  and  I  liave  generally  seen  such  supposed 
short  fingers  grow  longer  in  proportion  to  the  increased  experience  of  their 
possessors.  A  practised  examiner  will  usually  feel  all  there  is  to  feel  with 
one  finger  ;  the  beginner  can  do  no  more  with  two  than  one.  The  middle 
finger  alone,  which  I  have  seen  used  by  some,  is  manifestly  much  less 
convenient  than  the  index,  and  only  serviceable  in  the  absence  of  the 
latter. 

If  there  is  a  discharge  from  the  vagina,  which  possibly  may  originate 
in  the  uterus,  it  is  advisable  to  introduce  the  speculum,  preferably  the 
cylindrical,  before  making  a  digital  examination,  in  order  not  to  interfere 
with  the  secretion  from  the  cervix.  By  indagation,  and  especially  sound- 
ing, this  discharge  may  be  disturbed  or  removed,  and  a  valuable  point  for 
diagnosis  thus  lost. 

Dorsal  Position. — The  patient  is  placed  flat  on  her  back,  in  the  posi- 
tion indicated,  the  hips  well  down  to  the  edge  of  the  couch  or  table 
(which  should  be  on  a  level  with  the  pelvis  of  the  physician),  the  knees 

and  thighs  bent  and  abducted,  the 
feet  flat  on  the  couch  at  the  side 
of  the  hips.  The  hips  should  be  on 
a  level  with  the  head,  perhaps  even 
a  little  higher. 

The  rectum  has  been  emptied 
within  several  hours,  and  her  blad- 
der immediately  before.  The  face 
and  body  of  the  patient  are  covered 
with  a  thin  sheet,  which  protects 
her  modesty  and  prevents  her  from 
seeing  what  is  being  done.  The 
physician  washes  his  hands  carefully,  removes  all  impurities  from  under- 
neath his  nails,  and  searches  for  any  abrasion  on  his  index-fingers,  the  nails 
of  which  should  be  cut  close  and  smoothly  pared  and  rounded.  He  then 
anoints  the  forefinger  to  be  used  with  some  greasy  substance.  Both  in 
private  and  hospital  practice  vaseline  is  the  neatest  article  for  the  purpose, 
the  white  preparation  being  the  best.  Common  soap  may  also  be  employed. 
Any  non-irritant  fatty  substance  may  be  used,  such  as  sweet-oil,  glycerine, 
lard,  sweet  butter,  cold  cream ;  but,  as  a  rule,  the  liquid  substances  are 
inferior,  as  they  drop  from  the  finger  on  the  clothes  or  floor,  and  less 
effectually  protect  the  finger.  These  substances  may  be  carbolized  or 
thymolized  by  the  addition  of  one  or  two  grains  of  carbolic  acid  or  thymol 
to  the  ounce,  but  this  is  not  necessary.  The  thymol,  however,  makes  a 
very  pleasant  deodorizer. 

Before  introducing  his  finger  it  is  advisable  for  the  physician  now,  if 
this  is  the  first  examination,  to  inspect  the  vulva  and  introitiis  vaginse, 
by  lifting  the  clothes  and  stepping  to  one  side  to  admit  the  light.  Having 
surveyed  the  vulva  by  drawing  apart  the  labia  majora  with  finger  and 
thumb  of  one  hand,  or  the  fingers  of  both  hands,  he  gently  separates  the 
nymphse  and  exposes  to  view  the  meatus  urinarius,  the   vestibule,  the 


Fib.  13. — Eight  Hand  arranged  for  Digital  Exam- 
ination. 


DIGITAL    EXAMINATIOISr.  45 

vaginal  orifice.  Having  completed  the  inspection  (tlae  reasons  for  and 
advantages  of  which  have  already  been  enumerated  under  their  respective 
heads),  indagation  is  performed  in  the  following  manner  : 

The  physician  anoints  the  index-finger,   folds  the    three   last  fingers 
of  the  same  hand  as  tightly  into  the  palm  as  possible,  abducts  the  thumb, 
and   standing   between  the   thighs  of   the   patient,   slightly   toward   the 
thigh  corresponding  to  the  examining  hand,  places  the  index-finger  with 
the^volar  surface  nearly  upward  against  the  perineum,  and  passes  it  gently 
upward  until  it  almost  involuntarHy  slips  over  the  posterior  commissure 
into  the  cleft  of  the  vulva.     The  thumb  is  placed  gently  against  the  hori- 
zontal ramus  of  the  pubis  of  the  side  corresponding  in  name  to  the  hand 
used,  the  first  joints  of  the  three  fingers  are  pressed  against  the  yielding 
perineum.    Care  should  be  taken  not  to  give  pain  by  a  ring,  if  one  is  worn 
on  the  examining  hand.     Indeed,  it  is  a  good  rule  to  remove  such  a  ring 
before  proceeding  to  an  examination.     As  the  finger  slips  through  the 
vulvar  cleft  into  the  orifice  of  the  vagma,  it  notes  the  condition  of  the  peri- 
neum, its  integrity  or  laceration  ;  the  patulousness  of  the  vulvar  apertm^e ; 
the  rigidity  or  flabbiness  of  the  tissues  ;  the  moistui'e  or  dryness,  and  the 
sensitiveness  of  the  parts  ;  the  situation,  anterior  or  posterior,  of  the  oi-ifice  ; 
the  height  and  thickness  of  the  symphysis  pubis.     The  meatus  urinarius 
may  als'o  be  touched,  if  there  be  any  vesical  symptoms,  and  its  patulous- 
ness and  tenderness  noted  ;  and  the  finger  may  even  approach  the  chtoris, 
if  an  ocular  inspection  has  not  satisfied  the  physician  about  these  organs. 
But,  as  a  rule,  it  is  best  not  to  touch  the  chtoris,  especially  in  nei-vous 
excitable  women,  who  may  develop  erotic  symptoms  embarrassing  to  them- 
selves and  the  medical  attendant. 

The,  finger  is  now  passed  through  the  vaginal  orifice  into  the  canal  of 
the  vagina  ttself,  noting,  as  it  advances,  the  hymen  or  myrtiform  caruncles  ; 
the  condition  of  the  vulvo-vaginal  glands  (whether  swollen  or  not)  ;  the 
presence  or  absence  of  protrusion  of  the  anterior  or  posterior  vaginal  wall ; 
the  moisture,  and  proceeding  upward,  the   width,  length,   rugosity,   or 
smoothness  of  the  vaginal  canal.     The  tension  of  the  perineal  and  levator 
'  ani  muscles,  the  distance  between  the  tubera  ischii,  the  rigidity  or  promi- 
nence of  the  sacro-ischiatic  ligaments,  and  the  mobility  of  the  coccj^, 
are  further  points  to  be  considered.     Commencing  immediately   under 
the  symphysic  arch  and  extending  an  inch  upward  to  lose  itseK  gradually 
in  the  anterior  wall  of  the  vagma  is  a  ridge,  often  of  the  thickness  of  the 
little  finger,  the  urethra.     The  relations  and  sensitiveness  of  this  promi- 
nence, especially  at  the  point  where  it  ceases,  are  of  importance.     The 
separation  of  the  rami  of  the  pubic  arch  may  also  be  valuable  information 
in  prospective  obstetric  cases.     To  sui'vey  all  these  points  is  but  the  work 
of  a  moment  for  a  practised  finger.     To  neglect  them  and  rapidly  pass  the 
finger  to  the  organ  which,  in  the  majority  of  cases,  is  probably  at  fault— 
the  cervix  and  body  of  the  uterus— would  often  cause  the  examiner  to 
overlook  important  featui-es,  and  would,  in  my  opinion,  constitute  a  care- 
less and  hasty  examination.     Of  course,  the  order  of  exploration  may  be 
reversed  and  these  parts  examined  last,  if  the  physician  chooses.     But  I 


46 


GYNECOLOGICAL    EXAMIIfATION. 


prefer  to  proceed  sj-stematically  in  the  physical  as  well  as  the  oral  exami- 
nation. 

About  two-thirds  of  the  way  up  the  vagina,  between  two  and  three 
inches  from  the  orifice,  the  finger  meets  with  a  more  or  less  conical  projec- 
tion, the  cervix  uteri,  in  the  centre  of  which  is  an  opening,  the  external 
OS.  The  finger  should  be  swept  over  the  cervix  and  note  its  consistency 
and  shape ;  the  size  of  the  os,  the  condition  of  its  lips  or  edge,  whether 
smooth,  regular,  fissured,  hard  or  soft ;  the  presence  of  a  rent  in  one  or 
both  lips ;  the  existence  of  small  nodules  over  its  surface  (the  ovula  Nabo- 
thi),  the  rolling  out  or  eversion  of  the  cervical  mucous  membrane.  The 
direction  in  which  the  os  points  should  further  be  observed,  whether 
downward,  backward,  upward,  forward,  or  lateral ;  also  the  mobiHty  of 
the  cervix.  Having  examined  this  part  thoroughly,  the  finger  sweeps 
around  it  and  touches,  one  after  the  other,  the  anterior,  posterior,  and  lat- 
eral pouches  of  the  roof  of  the  vagina.  First,  the  point  of  reflexion  of  the 
vagina  on  the  cervix  is  noted,  whereby  the  length  of  the  iutravaginal  por- 
tion of  the  cervix  is  ascertained.  It  will  be  observed  that  the  vaginal  re- 
flection posteriorly  is  at  least  one-half  an  inch  higher  than  anteriorly. 

The  finger  is  then  passed  before  the  cervix  and  pushed  iipward  with  a 
view  to  feeling  for  a  firm  body,  the  fundus  uteri,  which  will  be  found 

there,  if  the  uterus  is  antedis- 
placed  ;  in  that  case  the  finger 
seeks  for  an  angle  between  the 
cervix  and  the  fundus  at  about 
the  vaginal  insertion,  and  by  its 
presence  diagnoses  an  anteflexion, 
by  its  absence  an  anteversiou. 
The  tenderness  and  mobility  of 
the  fundus  are  also  tested.  Pass- 
ing behind  the  cervix,  the  finger 
searches  for  the  like  firm  body 
which  it  vainly  sought  for  in 
front,  and  if  found,  seeks  the 
same  angle.  The  degree  of  the 
angle  should  be  noted,  and,  in 
either  case,  the  ease  with  which 
the  finger  reaches  the  anterior 
or  posterior  body  remembered 
as  indicating  the  degree  of  dis- 
placement. The  sensitiveness  and  mobility  of  the  posterior  body  are  of 
greater  importance  than  the  anterior,  owing  to  the  frequency  of  ad- 
hesions between  the  fundus  uteri  and  the  retro-uterine  peritoneal  pouch 
and  of  tumors  in  that  locality.  The  posterior  vaginal  pouch  is  further 
to  be  examined  for  small  movable  masses,  which  may  be  either  prolapsed 
ovaries,  or  scybala  in  the  rectum,  or  pediculated  retro-uterine  fibroids. 
Whenever  a  tumor  is  felt  adjacent  to  the  utei'us,  the  finger  should  en- 
deavor to  ascertain  whether  and  to  what  extent  it  is  connected  with  the 


Fig.  14. 


-Normal   Relations    of  Internal  Sexual  Organs 
(P.  F.  M.). 


DIGITAL    EXAMlNATIOTvT.  4/ 

uterus.  Further,  the  parametrium  should  be  carefully  examined  for  ir- 
regularities, nodosities,  and  tender  spots,  which  are  very  common,  and 
evidences  of  more  or  less  acute  or  chronic  cellulitis,  or  of  angio-leucitis. 
The  elasticity,  impressibility,  and  depth  of  the  vaginal  roof  are  also  a 
hio'hly  valuable  criterion  as  to  the  presence  or  absence  of  pelvic  peri- 
tonitis or  its  residues.  But  it  should  be  remembered  that  a  shallow 
vaginal  pouch  may  be  congenital,  or  the  result  of  imperfect  develop- 
ment. The  differentiation  between  this  condition  and  a  vaginal  roof 
depressed  by  superincumbent  plastic  exudation  is  easily  made  by  means 
of  the  normal  mobility  of  the  uterus  and  elasticity  of  the  vagina  in  the 
congenital  variety.  A  soft,  ropelike  swelling,  extending  from  the  middle 
of  the  posterior  wall  of  the  vagina  up  toward  the  left  along  the  sacral  ex- 
cavation, should  not  be  mistaken  for  a  neoplasm  ;  it  is  the  rectum,  and  can 
be  detected  by  its  moderate  mobility  in  the  upper  portion,  by  its  want  of 
tenderness  and  the  frequent  presence  in  it  of  a  soft  pultaceous  mass,  or 
hard,  movable  scybala.  .  The  normally  situated,  not  enlarged  ovaries  and 
tubes  can  seldom  be  felt  by  the  vaginal  touch  alone,  since  the  great  mobil- 
ity of  the  normal  ovary  enables  it  to  evade  the  intravaginal  finger  and 
prevents  the  latter  from  receiving  more  than  a  mere  susj)icion  of  its  pres- 
ence. As  a  rule,  the  normal  ovary  can  be  clearly  felt  in  women  with  av- 
erage adipose  development  only  by  bimanual  palpation,  and  then  only  by 
practised  hands.  If  the  ovary  is  prolapsed,  one  intravaginal  finger  can 
readily  detect  it  by  pressing  it  against  the  posterior  pelvic  wall,  when  the 
peculiar  olive  shape,  velvety  feel,  mobility,  and  the  characteristic  acute  pain 
on  sharp  pressure,  will  at  once  reveal  the  nature  of  the  body.  A\Taile  the 
normal,  not  enlarged  ovary  is  not  as  exquisitely  tender  on  pressure  as  the 
healthy  testicle,  my  experience  certainly  does  not  agree  with  that  of  those 
observers  who  claim  that  it  is  utterly  unsensitive  or  but  slightly  tender.  I 
have  almost  always  found  it  very  tender  if  the  pressure  was  at  all  severe,  and 
the  peculiar  pain  thus  produced,  as  it  were,  characteristic  and  entu'ely 
different  from  that  caused  by  pressure  on  the  other  pelvic  organs. 

Before  withdrawing  the  finger  the  mobility  of  the  cervix-  is  tested,  and 
care  taken  to  observe  whether  the  cervix  returns  to  its  original,  or  remains 
in  some  other  position. 

It  should  be  remembered  that  by  depressing  the  elbow  and  gently  but 
steadily  pushing  up  the  perineum  with  the  three  folded  fingers,  the  depth 
of  penetration  may  be  increased  by  at  least  an  inch.  If  the  patient's  peMs 
is  raised  by  herself  or  on  a  cushion,  the  posterior  portion  of  the  pehic 
cavity  is  still  more  approximated  to  the  examining  finger,  and  the  sacral 
promontory  may  even  be  reached  if  the  antero-posterior  diameter  of  the 
brim  is  the  least  shortened,  a  point  of  decided  importance  if  the  patient 
should  prove  to  be  pregnant.  On  withdrawing  the  fingers,  the  color,  odor, 
and  character  of  the  secretion  covering  it  should  be  noted,  as  ah'eady  men- 
tioned under  Inspection. 

Dr.  Eugene  C.  Gehrung,  of  Denver,  describes  an  improved  method 
of  vaginal  touch,  to  be  used  when  the  ordinary  touch  fails,  which  consists 
of   introducing  two  fingers  and  exaggerating  the  ali-eady  existing  position 


48  GYNECOLOGICAL    EXAMINATION". 

with  one  finger,  while  the  other  explores  the  anterior  or  posterior  vaginal 
fornix,  as  the  case  may  be.  By  thus  pushing  the  cervix  backward  in  an 
antedisplacement  the  anterior  siu*face  of  the  uterus  is  approximated  to  the 
finger  against  the  anterior  vaginal  wall ;  in  retrodisplacement,  the  cer\'ix  is 
elevated  toward  the  symphysis,  and  the  other  finger  more  readily  reaches 
the  posterior  uterine  wall  in  the  posterior  cul-de-sac.  The  ovaries,  broad 
Hgaments,  and  Fallopian  tubes  are  also  brought  nearer  to  the  finger  by 
this  method. 

Starting  from  without  inward,  certain  pecuHar  features  in  the  differ- 
ent sections  of  the  accessible  genital  tract  may  be  met  with,  and  will  de- 
note corresponding  physical  conditions.  Thus,  at  the  vulva,  enlai'ged 
pendulous,  highly  j)igmented  nymphae  may  lead  to  a  suspicion  of  onan- 
ism if  found  in  young  girls,  of  excessive .  sexual  indulgence  or  frequent 
partuiition  in  manied  women ;  a  highly  sensitive,  perhaps  enlarged,  or 
excoriated  cHtoris  indicates  a  nervous,  erotic  temperament,  or  onanism; 
erosions  on  the  labia  majora,  pruritus  vulvae,  or  the  presence  of  parasites, 
or,  if  flat  and  elevated,  either  specific  patches  or  follicuHtis,  the  diagnosis 
betAveen  which  is  not  always  easy ;  a  laceration  of  the  foui'chette  or  peri- 
neum, or  obUteration  of  the  caruncles  of  the  hymen,  speak  for  preceding 
parturition  ;  a  gaping,  patulous  vulvo-vaginal  orifice  for  jDluiijDarity.  An 
intact  hymen  with  shai-p,  unbroken,  spherical  or  crescentic  border  gener- 
ally jDroves  rirginity ;  still,  this  test  is  not  absolute,  since,  on  the  one 
hand,  the  membrane  may  be  so  elastic  as  to  peiTait  the  introduction  of 
the  j)enis  without  rupturing,  and,  on  the  other,  it  may  have  been  torn  or 
destroyed  by  treatment  or  disease.  Ordinarily,  a  hymen  torn  in  one  or 
several  places  down  to  its  attachment,  but  capable  of  being  restored  to  its 
normal  shape  by  the  coaptation  of  its  folds,  denotes  defloration  without 
parturition.  An  imperforate  and  bulging  vaginal  oiifice  would  speak  for 
retention  of  menstrual  fluid. 

A  joatulous  enlarged  urinary  meatus  may  be  due  to  artificial  dilatation 
for  diagnostic  jJurposes,  or  if  the  dilatation  be  excessive,  it  may  arise  fi-om 
the  habitual  use  of  that  canal  for  the  sexual  act.  Small  bright  red  bodies 
projecting  from  the  meatus  (hypei-plastic  papilfe,  caruncles)  generally  in- 
dicate painful  and  frequent  micturition.  A  red,  eroded,  tender  vaginal 
orifice  leads  to  the  suspicion  of  onanism  or  excessive  sexual  indulgence,  or 
an  irritating  vaginal  discharge. 

Passing  into  the  vagina,  a  protrusion  of  the  anterior  or  posterior  wall 
of  that  canal  shows  previous  partuiition  with  subsequent  subinvolution  of 
the  distended  vagina ;  a  rough,  nutmeg-grater-hke  feel  of  the  vaginal  sur- 
face shows  the  presence  of  a  hj-peremia  or  hj-perplasia  of  the  vaginal  pa- 
pillae, or  granular  vaginitis  ;  a  very  moist  sUppery  condition  of  the  passage 
speaks  for  hypersecretion,  perhaps  also  from  the  cerrical  canal.  Adhe- 
sions between  cervix  and  vagina  and  cicatricial  contraction  of  the  vagina 
are  evidences  of  adhesive  vaginitis,  either  of  puei-peral  origin,  or  in  conse- 
quence of  acute  specific  infection,  or  of  the  apphcation  of  strong  acid  and 
caustics.  Tense  bands,  mnning  backward  or  laterally  from  the  cervix  be- 
neath the  vaginal  wall  are  signs  of  old  parametran  celluhtis. 


DIGITAL    EXAMHSTATION". 


49 


A  long,  conical  pointed  cervix,  or  a  cervix  curled  up  anteriorly  \vith 
the  OS  pointing  upward,  or  a  minute,  "  pinhole  "  os,  are  generally  signs  of 
congenital  sterility ;  a  cicatricially 
contracted,  rigid  os  of  acquii-ed 
sterHity  (caustics).  A  small, 
round,  or  transverse  os,  with, 
smooth  h]DS,  denotes  nulliparity  ; 
a  gaping,  fissured  os,  with  irreg- 
ular, notched  hps,  often  admit- 
ting the  point  of  the  finger,  pluri- 
parity.  A  patulous  external  os  is, 
however,  met  with  also  in  nulli- 
parae, during  chronic  endotrache- 
litis,  and  after  the  use  of  cervical 
dilators  (tents)  and  recent  abor- 
tion. The  excessive  moisture  and 
softness  of  the  part  will  then  be 
noticeable.  On  the  other  hand, 
a  small,  transverse  os  may  oc- 
casionally be  met  with  in  women 
who  bore  one  or  more  children 

many   years    previously,     mthout      '''°-  IS-Retroversion  of  Anteflexed  ITterus  (P.  F.  U.). 

the  orifice  sustaining  injury  at  the  labor.  An  excessive  softness,  pulpiness 
of  the  whole  cervix  may  be  due  to  pregnancy,  as  indeed,  may  a  hyperse- 
cretion and  puffiness  of  the  va- 
gina and  labia  ;  but  in  a  nullipara 
an  unusually  soft  velvety  cervix 
frequently  indicates  a  catarrhal 
or  follicular  erosion  of  that  part, 
which  supposition  is  confirmed 
by  a  sanious  glaiiy  discharge  re- 
moved by  the  examining  finger. 

A  fissure  of  the  cervix,  either 
unilateral  or  bilateral,  of  greater 
or  lesser  depth,  merely  indicates 
that  the  patient  was  delivered 
of  a  child,  near  or  at  term,  but 
by  no  means  necessarily  implies 
that  the  labor  was  instrumental, 
or  that  the  medical  attendant 
was  to  blame  for  the  laceration. 
The  Hps  of  the  fissui-ed  cei-vix 
may  be  almost  in  apposition,  or 
thev  may  be  rolled  out  "  like  the 

Fio.  16.-Anteversion  of  Uterns  (P.  F.  M.).  ^^{^^^^  ^^  ^  Celery-stalk  "  (Good- 

ell),  with   everted  and  eroded  cervical  mucous   membrane.      Recently  I 
examined  a  young  girl  of  sixteen  years,  an  undoubted  virgin,  who  was  sent 
4 


50 


GYNECOLOGICAL   EXAMINATION. 


Fig.  17. — Anteflexion  of  Utems  (P, 


to  me  by  Dr.  E.  C.  Seguin  for  an  opinion  as  to  whether  her  epileptic  fits 
depended   on   uterine    disease,   and   to   my   surprise  found  an   apparent 

double  laceration  of  the  cervix 
with  eversion.  A  specular  ex- 
amination showed  a  catarrhal 
erosion  of  the  everted  cervical 
lips.  Unquestionably  this  was  a 
congenital  malformation.  Fisch- 
el,  of  Prague,  observed  a  double 
congenital  fissure  with  eversion 
of  the  cervix,  in  a  new-born  child. 
The  bare  possibihty  of  falsely  im- 
puting parity  to  a  woman  on  the 
strength  of  this  lesion  should, 
therefore,  be  borne  in  mind. 

The  surface  of  the  cervix  may 
be  smooth,  or  it  may  be  irregular, 
nodular,  as  though  lentils  or  small 
peas  were  distributed  under  its 
covering  ;  the  latter  condition  is 
due  to  the  presence  of  small  re- 
tention cysts,  the  occluded  muci- 
parous follicles  (or  ovnila  Nabothi 
of  the  old  anatomists)  from  which  the  peculiar  glairy  mucus  of  the  cervix 
is  derived.  Occasionally  this  nodular  condition,  particularly  if  associated 
with  simple  papillaiy  hyperplasia, 
may  become  so  excessive  as  to 
simulate  epithelioma.  Scarifica- 
tion of  the  nodioles  (if  follicles,  a 
glaiiy  fluid  exudes  and  they  col- 
lapse) and  the  microscope,  soon 
settle  the  diagnosis. 

A  hard,  almost  cartilaginous, 
enlarged  cervix  may  be  merely 
the  product  of  hyperplasia,  or  of 
caustics  applied  to  a  lacerated 
and  everted  mucous  membrane, 
or  it  may  be  the  first  stage  of 
scirrhous  disease.  The  micro- 
scope will  decide.  A  puffy,  mod- 
erately hard,  nodular  cervix,  en- 
larged to  twice  its  size  or  more, 
with  the  enlargement  generally 
extending  above  the  vaginal  re- 
flection, means  the  first  stage  of 
parenchymatous  cancer  ;  a  soft, 
readily  bleeding,  cauliflower-like  growth  of  large  size  is  an  epithelioma ;  a 


Fig.  18.— Anteflexion  of  Cervix  (P.  F.  M.). 


DIGITAL    EXAMINATION". 


51 


crater-shaped  excavation  of  the  immovable  cervix  permitting  the  finger  to 
enter  almost  to  the  os  internum,  with  irregular  edges  and  nodular  swelUngs 
imbedded  in  the  vaginal  wall,  is  the  second  or  ulcerative  stage  of  carci- 
noma :  all  these,  when  once  felt,  can  scarcely  be  mistaken. 

If  the  cervix  and  os  point  backward  toward  the  sacral  excavation  it  is 
probable  that  the  fundus  is  to  be  found  in  the  opposite  direction  ;  if  the 
cervix  is  felt  under  the  symphysis  the  finger  will  find  the  fundus  in  the 
posterior  cul-de-sac.  There  is  an  exception  to  this  last  rule,  and  that  is 
when  the  whole  uterus  is  pushed  forward  and  upward  by  a  retro-uterine 
tumor ;  the  uterus  is  then  generally  straight,  and  the  fundus  inaccessible 
to  the  vaginal  touch.  In  flexions 
of  the  uterus,  the  cervix  often 
retains  almost  the  normal  posi- 
tion, with  the  OS  pointing  down- 
ward, slightly  forward  or  back- 
ward ;  the  finger  detects  the  angle 
at  the  anterior  or  posterior  vagi- 
nal insertion,  which  settles  the 
diagnosis  between  flexion  and 
version, 

A  deviation  of  the  cervix  to- 
ward one  or  the  other  wall  of  the 
pelvis  generally  means  a  corre- 
sponding deviation  of  the  fundus 
toward  the  other  side,  a  right  or 
left  latero-version.  Such  latero- 
versions  usually  depend  on  con- 
tracting adhesions  in  the  broad 
Hgament,  which  di"aw  either  the 
cervix  (generaUy)  or  the  fundus  ^'^-  ^^--i^^t^^^'  ^^°^  of  ^te™«  (p-  ^-  ^■^■ 

toward  the  affected  side.  Occasionally  the  fundus  is  found  on  the  same 
side  as  the  cervix,  and  the  uterus  is  either  straight  or  latero-flexed  ;  this 
condition  is  usually  congenital. 

Passing  the  finger  into  the  vaginal  fornix,  the  solid  body  usually  felt 
in  front  of  the  cervix  is  the  fundus  uteri.  Tumors  are  rare  in  this  locality ; 
seldom  an  enlarged  and  anteprolapsed  ovary,  more  commonly  a  uterine 
fibroid,  an  ante-uterine  hematocele  or  cellulitic  exudation.  The  bladder  is 
ordinarily  not  recognizable  to  the  finger ;  only  when  it  is  distended  or 
hypertrophied  (as  in  cystitis)  does  it  impart  an  elastic  resistance  to  the 
finger.  In  two  instances  I  have  detected  a  hypertrophied  ureter  through 
the  anterior  vaginal  wall,  in  both  cases  the  left.  At  the  autopsy  of  one  of 
the  cases  the  left  ureter  was  found  enormously  enlarged  by  hypertrophy 
of  its  walls,  due  to  the  irritation  of  pus  passing  through  it  from  a  pyelitis 
of  the  left  kidney. 

In  the  posterior  fornix  the  finger  meets  with  various  tumors  of  difier- 
ent  nature  and  origin,  which  often  require  the  utmost  ingenuity  to  de- 
cipher.    The  most  common  of  all  is  the  retroverted  or  retroflexed  uterine 


52 


GYNECOLOGICAL    EXAMHSTATIOISr. 


body,  next  a  subperitoneal  uterine  fibroid,  a  small  ovarian  tumor,  a  cellu- 
litic  or  peritonitic  exudation  tumor,  a  hematocele,  most  rare  a  pelvic  eccbino- 
coccus  tumor,  sacral  carcinoma,  or  exostosis.  The  differential  diagnosis 
between  these  various  growths  is  often  exceedingly  difiicult  to  the  vagi- 
nal touch,  especially  when  a  diffuse  pelvic  peritonitis  has  fixed  an  ordinarily 
movable  tumor.  As  a  rule,  the  fundus  uteri  is  oblong,  soft,  elastic,  tender ; 
a  fibroid  hard  and  elastic,  perhaps  nodular  ;  an  ovarian  tumor,  also  soft, 
elastic,  more  sj)herical,  and  slightly  tender  ;  a  celluHtic  exudation  or  hema- 
tocele, when  recent,  soft,  doughy,  impressible,  veiy  tender  ;  when  older, 
board-hardj  dense,  scarcely  sensitive.     The  fundus,   fibroid,   and  ovarian 

tumor  are  movable,  together  with 
the  uterus,  unless  they  be  ad- 
herent. A  pelvic  exudation  tumor 
or  hematocele  is  absolutely  im- 
movable. If  the  retrocervical  tu- 
mor is  movable,  the  finger  may 
gradually  push  it  up  and  its  re- 
lations become  entirely  altered. 
Thus,  recently,  a  retro-uterine 
tumor,  which  first  apjDeared  like 
a  retroflexed  fundus,  but  was 
readily  discovered  not  to  be  such 
when  the  fundus  was  felt  anteri- 
orly by  palpation,  was  diagnosed 
as  a  subperitoneal  fibroid,  until 
it  was  pushed  up  by  repeated 
touching,  and  finally  showed  its 
origin  in  the  left  broad  ligament, 
namely,  an  ovarian  tumor. 

Another  mass  frequently  felt 
m.  20.-Eetroflexion  oftJteros  (P.  F.  M.).  behind  the  utcrus  is  the  loaded 

rectum,  with  its  pultaceous  or  scybalous  contents,  which  are  recognized 
by  the  impressibihty  of  the  tumor  and  the  number  of  the  scybala. 

A  retro-uterine  tumor,  for  which  I  have  repeatedly  seen  beginners  take 
scybala,  is  the  prolapsed,  and  slightly  enlarged,  ovary.  A  flat,  movable, 
tender  body,  of  the  size  of  an  almond  or  small  fig,  is  felt  directly  behind 
the  cervix,  often  at  the  very  bottom  of  Douglas'  pouch,  on  a  level  with  the 
external  os,  or  two  such  bodies  may  be  found  slightly  to  each  side  of 
the  median  hue.  If  these  bodies  are  flat  and  but  little  enlarged,  they  are 
tender  only  on  severe  pressui-e  ;  but  if  enlarged,  they  are  generally  ex- 
quisitely tender.  These  bodies  can  be  taken  for  nothing  but  the  ovaries  ; 
they  are  often  so  movable  as  to  require  two  fingers  to  catch  and  hold 
them. 

In  each  lateral  pouch  the  finger  in  normal  cases  feels  merely  a  soft 
elastic  resistance.  A  very  frequent  sensation  in  that  region  is  a  moder- 
ately firm,  smooth,  often  convex  tumor,  which  is  more  or  less  tender,  and 
at  times  has  a  doughy,  boggy  feel,  giving  evidence  of  deep-seated  suppu- 


DIGITAL    EXAMINATIOlSr.  53 

ration.  Or  the  tumor  may  be  hard,  or  freely  fluctuating.  This  is  a 
cellulitis  between  the  layers  of  the  broad  ligament  and  latero-uterine  con- 
nective tissue.  If  the  tumor  feels  shrunken,  hard,  and  is  devoid  of  tender- 
ness, it  is  not  of  recent  origin.  Irregular,  flat,  more  or  less  tender  nodules 
are  often  felt  in  different  parts  of  the  retro-lateral  pelvic  connective  tissue, 
which  are  the  residue  of,  often  unsuspected,  celMitis  in  former  years,  or 
are  enlarged  lymphatic  glands. 

Lateral  and  Later o- abdominal  Position. — The  physician,  standing  slightly 
behind  the  patient,  introduces  the  index-finger  of  the  hand  opposite  to  the 
side  on  which  the  patient  is  lying  (left  side,  right  hand  ;  right  side,  left 
hand)  into  the  vagina  with  the  palmar  surface  directed  backward.  The 
finger  may  be  slipped  over  the  fourchette,  as  in  the  dorsal  position,  or 
backward  from  the  clitoris,  and  its  introduction  will  be  facilitated  by  lift- 
ing the  superior  buttock,  and  thus  separating  the  labia,  with  the  other 
hand.  If  the  orifice  be  sufficiently  large,  two  fingers  ma^^  be  introduced 
in  this  position,  and  will,  I  have  found,  be  much  more  serviceable  now 
than  in  the  dorsal  position,  since  they  enable  the  examiner  to  explore  also 
the  lower  half  of  the  pelvic  cavity,  and  to  reach  farther  up  by  retracting  the 
perineum.  The  chief  advantage  of  indagation  in  this  position  is  the  possi- 
bility of  touching  the  upper  portion  of  the  pelvic  cavity  (that  corresjDond- 
ing  in  name  to  the  examining  hand),  and  the  sacral  excavation  more  readily 
than  in  the  dorsal  position.  Thus  prolapsed  ovaries  and  posterior  and 
lateral  plastic  exudations  are  often  more  easily  felt  in  the  lateral  position. 

The  semiprone  position  offers  no  advantages  over  the  lateral  for  indaga- 
tion ;  on  the  contrary,  the  uterus  and  its  movable  adnexa  are  removed  from 
the  finger  by  gravitation  in  the  former  position.  This  very  fact  may,  how- 
ever, occasionally  be  useful  by  showing  the  mobility  of  the  normal  organs 
or  of  intrapelvic  tumors,  and  thus  aid  in  settling  a  diagnosis.  Anomalies 
of  the  coccyx  and  sacrum  are  also  more  easily  diagnosed  in  the  lateral 
decubitus.  The  majority  of  gynecologists  use  the  hand  opj)oscd  in  name 
to  the  lateral  decubitus,  as  above  described  ;  and  it  requires  but  a  trial  to 
convince  any  one  that  anatomically  this  is  the  most  convenient  and  usefid 
hand  for  the  purpose.  Still,  so  prominent  a  gynecologist  as  Barnes  recom- 
mends using  the  left  index-finger  in  the  left  lateral  position.  To  me  this 
practice  is  extremel}^  awkward  and  inconvenient,  for  I  can  only  feel  the 
lower  half  of  the  peMc  cavity  with  the  sensitive  volar  surface  of  the  finger, 
and  am  compelled  to  turn  and  t'svist  my  hand,  in  the  most  imcomfortable 
fashion,  to  reach  the  posterior  and  upper  portions  of  the  cavity.  To  recom- 
mend the  left  lateral  position  and  the  left  hand  for  ordinary- vaginal  exami- 
nation seems  to  me  merely  laying  unnecessary  difficulties  in  the  way  of  the 
student  without  the  least  compensating  advantage. 

The  knee-chest  or  elbow  position  is  not  convenient  for  a  digital  examina- 
tion, as  the  gravitation  of  the  viscera  away  from  the  pelvis  elongates  the 
vagina  so  much  as  to  render  the  cervix  and  vaginal  vault  less  accessible  to 
the  finger  than  in  the  dorsal  position.  Only  when  it  is  desirable  to  ascer- 
tain the  mobility  or  attachment  of  certain  intrapeMc  tumors  will  secondary 
knee-breast  indagation  occasionally  prove  serviceable. 


54  GYNECOLOGICAL    EXAMINATION. 

Erect  Position. — The  physician  kneels  on  one  knee,  that  correspond- 
ing to  the  examining  hand  being  preferable,  or  sits  on  a  chair  with 
his  body  bent  forward ;  the  patient  stands  before  him,  with  separated 
thighs  and  slightly  inclined  body,  steadying  herself  with  one  hand  on  the 
shoulder  of  the  physician  or  the  back  of  his  chair,  or  he  may  support  her 
by  grasping  her  corresponding  hip  with  his  free  hand  ;  or  she  needs  no 
support  whatever.  Introducing  his  hand  under  the  clothes,  which  the 
patient  herseK  may  hold,  he  easily  passes  his  forefinger  into  the,  in  this 
position,  generally  gaping,  vulvo-vaginal  orifice,  or,  the  usual  rule  of  sHp- 
ping  forward  from  the  jDerineum  may  be  observed  ;  and  then,  the  relations 
between  the  hand  and  \Tilva  being  the  same  as  in  the  dorsal  position,  seeks 
the  cervix,  which  will  generally  be  found  lower  in  this  posture.  The  in- 
fluence of  the  erect  position  and  the  thereby  increased  intra-abdominal 
pressure  on  the  movable  pelvic  organs  has  been  explained  in  the  descrip- 
tion of  that  position,  and  it  is,  therefore,  evident  that  the  cervix,  vaginal 
roof,  and  ovaries  in  the  normal  state,  and  still  more  in  relaxed  conditions, 
and  movable  tumors  of  these  organs,  are  then  more  accessible  to  the  fin- 
ger. It  is,  therefore,  advisable  always  to  examine  patients,  in  whom  a 
downward  displacement  of  the  uterus  or  vagina  is  suspected,  in  this  posi- 
tion and  thus  ascertain  the  extreme  existing  displacement.  After  the  ad- 
justment of  pessaries  for  any  form  of  uterine  or  vaginal  displacement  the 
amount  of  support  afforded  by  the  instrument  can  best  be  ascertained  by 
examining  the  patient  in  the  erect  posture,  and  directing  her  to  increase 
the  intra-abdominal  pressure  by  straining.  In  case  of  haste,  or  when  it  is 
merely  desu'ed  to  ascertain  whether  a  pessary  introduced  some  time  before 
is  still  in  place  and  doing  well,  this  posture  may  further  be  emj)loyed  as 
less  laborious  and  lengthy  for  physician  and  patient.  The  tension  of  the 
vaginal  roof  in  this  position  will,  as  a  rule,  prevent  the  finger  from  pushing 
up  that  septum,  as  can  be  done  in  the  dorsal  position.  Displacements, 
both  anterior  and  posterior,  and  also  flexions,  of  the  uterus,  are  aggravated 
by  the  erect  postiu'e,  although  in  a  less  measure  than  the  various  degrees 
of  prolapsus. 

b.  Rectal  Touch. 

A  digital  examination  per  rectum  may  be  required  when  an  obstruction 
exists  to  the  introduction  of  the  finger  into  the  vagina  (imperforate  hymen, 
atresia,  or  stenosis  vaginae,  vulvar  and  vaginal  tumors),  or  when  it  is  de- 
sired to  control  the  results  of  a  vaginal  exploration,  or  when  the  patient 
complains  of  pain  during  defecation  or  of  any  symptom  referable  to  the 
rectum.  Attention  should  in  every  case  be  paid  to  the  rectum,  in  order 
that  concealed  disease  of  that  organ  may  not  be  overlooked,  but  generally 
a  visual  examination  will  suffice,  unless  special  reasons  call  for  more.  The 
sj)ecial  advantage  of  a  rectal  examination  is  the  greater  accessibility  of  the 
retro-uterine  organs  and  the  posterior  wall  of  the  uterus.  This  advantage 
is  particularly  available  in  ascertaining  the  extent  and  attachment  of  retro- 
uterine tumors  and  cellulo-peritonitic  exudations. 


EECTAL    TOUCH.  00 

Emmet  examines  every  patient,  who  consults  him  the  first  time, 
through  the  rectum,  and  claims  that  he  can  touch  the  broad  ligaments  and 
all  the  retrolateral  uterine  tissues  so  well  in  this  manner  that  he  often  dis- 
covers small  cellulo-peritonitic  exudations,  adhesions,  and  contractions,  of 
which  the  histoiy  and  symptoms  give  no  idea,  but  which  accounted  for 
many  displacements,  distortions,  and  obscure  complaints,  the  cause  of 
which  would  otherwise  have  been  a  mystery,  and  the  treatment  correspond- 
ingly vague. 

Before  examining  the  rectum,  several  precautions  should  be  employed  : 
1.  The  bowel  should  be  thoroughly  evacuated  and  cleansed  by  means  of 
injections  shortly  previous  to  the  examination.  2.  The  space  under  the 
nail  of  the  examining  finger  should  be  filled  with  soap,  to  prevent  the  in- 
troduction of  fecal  or  other  matter  under  the  nail.  3.  If  the  finger  is 
withdrawn  from  the  vagina  to  be  immediately  inserted  into  the  rectum,  it 
should  be  cleansed  and  freshly  anointed,  in  order  to  avoid  contamination 
of  the  dehcate  mucous  membrane  of  the  rectum  by  the  vaginal  secretion. 

These  precautions  having  been  observ^ed,  the  finger,  well  anointed,  is 
gently  introduced  into  the  rectum.  The  resistance  of  the  external  siDhinc- 
ter  is  usually  overcome  without  difficulty  or  pain.  As  a  rule,  it  is  not  ad- 
visable to  tell  the  patient  what  is  about  to  be  done  (the  directions  for 
cleansing  the  rectum  should  be  given  before  every  appointed  vaginal  ex- 
ploration), but  anticipate  any  objection  she  may  make  by  at  once  introdu- 
cing the  finger  into  the  rectum.  As  the  finger  f)asses  the  sphincter,  notice 
should  be  taken  of  pain  experienced  or  hemorrhoidal  tumors  felt,  which 
may  require  subsequent  inspection.  The  first  object  the  finger  meets  is  a 
thick,  conical  body  projecting  into  the  anterior  wall,  the  cervix  uteri, 
which  through  the  rectum  aj)pears  nearer  and  is  more  easily  reached,  and 
gives  the  impression  of  being  larger  than  per  vaginam.  Passing  up  be- 
hind the  cervix  the  finger  examines  the  posterior  wall  of  the  uterus,  and 
the  intei-vening  pouch  of  Douglas  ;  thence  j)roceeds  to  touch  the  posterior 
wall  of  the  rectum,  and  the  surface  of  the  sacral  excavation.  Strictures, 
polypi,  cancerous  degeneration  of  the  rectum,  and  affections  of  the  retro- 
uterine pelvic  tissues  are  thus  easily  recognized.  Great  assistance  is 
afforded  this  examination,  by  seizing  the  cervix  per  vaginam  with  a  vrJ- 
sella,  drawing  it  down  as  far  as  practicable,  and  at  the  same  time  exploring 
the  posterior  uterine  surface  with  the  finger  in  the  rectum.  This  ma- 
neuvre  is  particularly  valuable  in  deciding  the  attachment  of  retro-uterine 
tumors. 

As  a  rule,  one  finger  suffices  for  a  rectal  examination.  The  introduc- 
tion of  two  wiU  usually  give  pain  and  probably  be  of  no  particular  service. 

The  recto-vaginal  touch  is  a  combination  of  the  two  methods.  It  con- 
sists in  introducing  the  index-finger  into  the  vagina  and  the  thumb  of  the 
same  hand  into  the  rectum  ;  or  the  thumb  into  the  vagina  and  the  index 
into  the  rectum  ;  or  the  index  into  the  vagina  and  the  middle  finger  into 
the  rectum.  Between  the  two  fingers  the  recto-vaginal  septum  and  the 
bottom  of  Douglas'  pouch  can  be  thoroughly  touched,  the  finger  in  the 
vagina  controlling  the  observations  of  the  one  in  the  rectum,  and  vice 


56  GYNECOLOGICAL    EXAMHSTATION. 

versa.  The  utility  of  tliis  metliod  ia  evidently  limited  by  the  length  and 
mobility  of  the  fingers. 

Shoiild  the  sphincter  be  so  irritable  as  to  deny  admittance  to  the  fin- 
ger, the  examination  may  have  to  be  made  under  anesthesia,  and  perhaps 
the  sphincter  forcibly  dilated.  This  is  always  the  case  ■when  Simon's 
method,  the  introduction  of  the  lohole  hand  into  the  rectum,  is  to  be  em- 
ployed. This  method  was  first  demonstrated  and  elaborated  by  the  late 
Prof.  Simon,  of  Heidelberg,  and  consists  in  gradually  passing  finger  after 
finger  through  the  sphincter,  until  the  whole  hand  is  introduced  ;  the 
hand  is  then  carried  up  gently  thi'ough  the  wide  rectal  pouch,  to  the  nar- 
rower entrance  of  the  sigmoid  flexure,  through  which  the  points  of  the 
fingers  project.  The  movable  intestine  can  now  be  carried  upward  with- 
out thrusting  the  hand  through  the  narrow  part  of  the  gut,  and  the  lower 
portion  of  the  abdominal  cavity  readily  palpated.  I  myself  have  felt  the 
kidneys,  and  reached  to  the  umbihcus  in  this  manner.  There  is,  gener- 
ally, if  the  hand  be  of  moderate  size  (not  larger  than  twenty  centimetres 
in  circumference  at  the  knuckles),  no  injury  done  to  the  sphincter  other 
than  a  few  nicks,  and  incontinentia  alvi  seldom  lasts  more  than  a  few 
days.  The  utihty  of  this  method  in  settling  the  diffei'ential  diagnosis  be- 
tween abdominal  tumors,  and  particularly  the  nature  of  their  attachments 
and  the  presence  of  adhesions,  is  obvious.  Unfortunately,  the  dangers  of 
the  hyjDerdistention  of  the  upper  portion  of  the  intestine  to  a  great  extent 
counterbalance  its  advantages.  Several  cases  of  rupture  of  the  peritoneal 
covering  of  the  sigmoid  flexure,  followed  by  peritonitis  and  death,  have 
occurred  in  both  sexes,  and  I  believe  the  profession  are  now  unanimous  in 
relegating  this  original  but  heroic  method  to  instances  in  which  the  risk 
is  justified  by  the  exigencies  of  the  case. 

The  counter-indications  to  the  examination  of  the  rectum  by  one  or  two 
fingers  exist  mainly  in  objections  on  the  part  of  the  patient,  in  the  presence 
of  fissures,  ulcers,  or  hemorrhoids,  rendering  this  maneuvre  painful  or 
difficult,  and  in  strictures,  rendering  it  impracticable.  The  presence  of 
mucous  patches  or  venereal  warts  at  the  anus  may  present  obstacles  in  the 
interest  of  the  physician,  as  also  the  distention  of  the  rectum  by  feces. 
More  serious  and  effectual  objections  are  offered  to  the  introduction  of  the 
ichole  hand  by  an  unusually  narrow  sphincter  or  intestine,  by  more  or  less 
recent  peritonitic  adhesions,  and  by  debilitj^  of  the  patient.  All  these  ob- 
jections may  gradually  be  overcome  by  proper  remedial  means. 

Recto-abdominal  palioation  will  be  discussed  later  on. 

c.    Vesical  Touch. 

The  introduction  of  the  finger  into  the  bladder  necessitates  the  previous 
dilatation  of  the  urethra,  and  is  therefore  a  method  of  examination  not  to 
be  undertaken  hastily  or  without  due  deliberation,  and  justifiable  only  when 
the  ordinary  means  are  insufficient  for  a  diagnosis.  The  dilatation  of  the 
urethra  should  be  looked  upon  as  an  operation,  and  should  ordinarily  be 
X^erfoiTned  only  under  anesthesia,  to  be  followed  immediately  by  the  in- 


VESICAL    TOUCH.  0/ 

troduction  of  the  finger.  Tlie  details  of  tlie  operation  will  be  described 
hereafter. 

The  vesical  touch  for  the  diagnosis  of  utero-pelvic  disease  has  recently 
been  elaborated  and  extensively  practised  by  Dr.  Emil  Noeggerath,  of  New 
York.  It  is  chiefly  useful  in  cases  where  it  is  desii'able  to  feel  the  anterior 
surface  of  the  uterus,  the  broad  ligaments,  and  the  utero-vesical  pouch  of 
the  peritoneum,  as  in  ante-uterine  fibroids,  small  ovarian  tumors,  and  ovarian 
hernia.  As  in  the  rectal  touch,  the  uterus,  ovaries,  and  broad  ligaments 
are  rendered  more  accessible  by  di'awing  them  down  by  a  vulsella  fastened 
into  the  cervix.  The  vesical  touch  may  be  required  only  to  ascertain  the 
condition  of  the  mucous  membrane  of  the  bladder,  and  the  presence  of 
foreign  bodies  in  that  viscus. 

If  it  is  desired  to  touch  the  urethra  only  to  and  thi^ough  its  entrance 
into  the  bladder,  the  little  finger  wiJl  suffice,  and  the  urethra  need  be  dilated 
only  to  that  width ;  but  if  the  interior  of  the  bladder  or  the  adjacent  or- 
gans are  to  be  touched,  the  whole  index-finger  must  be  introduced. 
"Whether  index  or  little  finger,  the  other  fingers  are  best  disposed  of  by 
being  fiexed  in  the  joalm,  and  pressed  as  far  as  possible  into  the  vulvar 
cleft.  The  examining  finger  then  has  its  palmar  surface  downward,  and  is 
thus  best  able  to  feel  the  parts  before  it ;  of  course,  it  is  rotated  as  occasion 
demands.  Or  the  middle  finger  may  be  passed  into  the  vagina.  The  pa- 
tient occupies  the  dorsal  or  gluteo-dorsal  position.  If  the  instrumental 
dilatation  has  been  thorough  the  finger  will  readily  slip  into  the  bladder  ; 
but  if  it  has  been  incomplete,  the  finger  will  gently  conclude  the  dilata- 
tion, and  this  is  generally  the  way  in  which  this  examination  is  performed. 
The  chief  obstruction  met  with  by  the  finger  is  at  the  ring  of  the  meatus, 
and,  this  overcome,  at  the  (so-called)  sjDhincter  of  the  bladder.  Either 
hand  may  be  used  as  most  convenient.  The  lining  membrane  of  the  blad- 
der, in  the  normal  condition,  has  a  soft,  velvety  feel.  Simon  has  felt  the 
mouths  of  the  lu'eters  and  passed  a  sound  into  them  ;  only  the  most  prac- 
tised touch  will  succeed  in  this  maneuvi'e. 

The  vesico-abdominal  examination  will  be  described  hereafter. 

The  counter-indications  to  the  vesical  touch  are  such  as  would 
render  the  preliminary  dilatation  of  the  urethra  dangerous,  or  productive 
of  lasting  injury — such  as  recent  para-  or  jDerimetric  inflammation,  or 
excessive  fragility  or  rigidity  of  the  urethral  tissiies,  whereby  serious 
laceration  or  permanent  incontinence  might  be  induced.  The  lu-ethra 
once  dilated,  there  can  be  no  objection  to  the  gentle  introdiiction  of  the 
finger. 

The  vesico-rectal  touch  consists  in  the  simultaneous  introduction  of  the 
index-finger  of  each  hand  into  the  bladder  and  rectum  respectively.  It  is 
chiefly  of  use  in  diagnosing  inversion  of  the  uterus,  in  which  condition  the 
doubtful  regiofl  of  the  cerrix  uteri  can  be  thoroughly  examined  by  the  two 
fingers  thus  employed.  This  manipulation  may  also  be  of  great  utility  in 
effecting  reduction  of  the  inversion,  the  two  thumbs  in  the  vagina  pressing 
up  the  fundus,  while  the  indices  in  bladder  and  rectum  dilate  the  cervical 
ring. 


58  GYNECOLOGICAL    EXAMHSTATION". 

E.   Bimanual  Examination. 

By  conjoined  or  bimanual  examination  or  palpation  is  meant  tlie  simul- 
taneous palpation  of  the  abdomen  with  one  hand,  while  the  other  is  explor- 
ing one  of  the  three  female  pelvic  canals.  We  thus  have  vagino-abdominal, 
recto-abdominal,  and  vesico-abdominal  bimanual  examination,  accordingly 
as  the  finger  is  introduced  into  one  or  the  other  of  these  cavities. 

The  simultaneous  use  of  the  external  hand  in  depressing  or  steadying 
the  movable  abdomino-pelvic  organs,  or  moving  them  about,  or  palpating 
their  surfaces,  or  feehng  any  motion  imparted  to  them  by  the  internal  ex- 
amining finger,  is  of  incalculable  benefit  in  determining  the  shape  and  posi- 
tion of  these  organs,  or  the  presence  of  pathological  formations  in  that 
locality.  Without  bimanual  examination  but  a  very  imperfect  conception 
of  the  pelvic  contents  can  be  obtained,  and  the  indications  for  its  employ- 
ment are  therefore  embodied  in  the  brief  and  comprehensive  sentence  : 
Wherever  indagation  is  to  he  performed,  there  also  is  simidtaneous  abdominal 
palpation  called  for.  The  physician  should  accustom  himself  never  to  intro- 
duce his  finger  into  the  vagina,  rectum,  or  bladder  without  at  the  same 
moment  placing  the  other  hand  on  the  abdomen  of  the  patient,  prepared 
to  exercise  whatever  manipulation  the  case  may  demand.  The  patient 
should  therefore  always  occupy,  whenever  practicable,  a  position  favorable 
for  the  relaxation  of  the  abdominal  muscles  and  the  diminution  of  intra- 
abdominal pressure,  as  well  as  convenient  for  palpation,  i.e.,  the  dorsal 
position. 

The  counter-indications  are  the  same — spasmodic  contractions,  inflam- 
mation, hyperesthesia  of  the  abdominal  walls — as  those  interfering  with 
simple  palpation. 

As  the  manipulation  is  essentially  the  same,  whether  the  internal  finger 
be  in  the  vagina,  the  rectum,  or  the  bladder,  I  shall  group  these  three 
divisions  under  the  same  heading,  and  describe  them  together  : 


a.    Vagino-abdominal ;    b.  recto-abdominal ;    c.  vesico-abdominal — Examina- 
tion. 

a.  Vagino-abdominal. — As  the  finger  passes  up  the  vagina,  the  other 
hand  is  placed  gently  with  extended  fingers  on  the  abdomen  of  the  patient 
(the  clothes  having  first  been  sufficiently  loosened  and  lifted  to  give  per- 
fect freedom  to  the  hand).  As  soon  as  the  internal  finger  has  completed 
its  survey  of  the  cervix,  and  the  four  quarters  of  the  vaginal  roof,  the  ex- 
ternal hand  gradually  and  gently  increases  its  downward  pressure,  com- 
mencing first  midway  between  umbiUcus  and  symphysis  over  the  usual 
site  of  the  fundus  uteri,  and  endeavoring  either  to  press  this  body  toward 
the  internal  finger,  or  to  grasp  it  completely  between  thumb  and  fingers. 
In  this  manner  an  existing  ante-  or  retrodisplacement  is  aggravated  and 
rendered  more  clear  to  the  internal  finger  ;  or  the  normal  position  of  the 
fundus,  previously  suspected  by  the  absence  of  a  large  body  in  either 


BIMANUAL    EXAMINATION". 


50 


vaginal  pouch,  is  assured.  Besides  the  position,  the  size,  shape,  and  con- 
tour of  the  fundus  and  body  of  the  uterus  may  thus  be  accurately  deter- 
mined, the  internal  finger  pushing  the  fundus  up  toward  the  outer  hand, 
and  placing  it  directly  between  the  two  hands.  In  shape  the  uterus  is 
best  likened  to  a  pear  compressed  antero-jDosteriorly  (the  old  comparison 
of  the  text-books  cannot  be  improved  upon)  ;  it  is  two  and  a  half  inches 
long,  of  which  about  one  inch  is  intravaginal ;  about  one  inch  thick,  and 
nearly  two  inches  wide  at  the  fundus.  An  experienced  touch  can  readily 
detect  even  a  slight  increase  in  these  dimensions.  But  it  should  be  re- 
membered (and  this  is  a  rule  which  holds  good  in  computing  the  size  of 
all  abdominal  tumors)  that  one  is  very  liable  to  overestimate  the  size  of 
the  uterus  as  felt  through  the  vaginal  and  abdominal  walls,  probably  be- 
cause the  thickness  of  its  envelopes  adds  to  its  apparent  size.     The  size  of 


Fig.  21.— Bimanual  Examination  (P.  F.  M.). 

the  uterus  can  usually  be  ascertained  only  in  this  manner,  and  it  is  evident 
that  this  maneuvre  is  of  the  greatest  importance  in  diagnosing  moderate 
enlargement  of  the  uterus,  as  it  occurs  dui-ing  the  first  two  or  three  months 
of  pregnancy,  during  subinvolution  or  areolar  hyperplasia,  or  in  intra- 
uterine growths  of  moderate  dimensions.  To  detect  a  pregnancy  of  six 
weeks  by  this  method  (the  only  means  by  which  it  can  be  detected  with 
any  probable  certainty,  when  aided  by  rational  signs)  requires  unusual 
dexterity,  and  especially  favorable  physical  circumstances  ;  even  at  two  and 
two  and  a  half  months  the  diagnosis  is  not  always  an  easy  one.  The  regu- 
lar spherical  outline  of  the  uterine  body,  and  the  apparent  equality  of  its 
antero-posterior  and  transverse  diameters,  may,  aided  by  the  soft,  velvety 
cervix,  assure  the  diagnosis.  Besides,  the  soft,  regular,  obscurely  elastic 
feel  of  the  uterus  gives  an  inkling  of  the  presence  of  fluid,  xls  already 
stated,  to  avoid  voluntary  or  reflex  contraction  of  the  abdominal  walls,  the 


CO  gyjStecological  examination. 

pressure  should  be  gentle  and  gradual ;  the  fingers  should  be  but  slightly 
cum^ed,  and  the  parietes  pressed  inward  until  some  firmer  body  is  more  or 
less  obscurely  felt.  A  pawing,  or  a  rubbing  motion  of  the  tips  of  the  fin- 
gers, whereby  the  abdominal  wall  is  moved  back  and  forth,  or  from  side 
to  side  over  the  part  under  process  of  palpation,  or  that  part  is  pressed 
against  and  again  withdrawn  from  the  internal  finger,  will  generally  serve 
to  give  both  hands  a  touch  of  all  its  surfaces.  Frequently,  in  lax  abdom- 
inal walls,  the  finger  in  the  anterior  or  posterior  cul-de-sac  and  the 
external  fingers  may  be  made  to  touch  with  only  the  intervening  abdom- 
inal and  vaginal  walls  between  them,  and  in  such  cases  the  surfaces  of 
the  uterus,  ovaries,  and  broad  ligaments  are  readily  accessible.  Later- 
ally, the  double  folds  of  the  broad  ligaments  generally  prevent  the  fingers 
from  meeting. 

The  beginner  usually  finds  some  difiiculty  in  detecting  the  fundus  uteri 
by  bimanual  examination  ;  he  either  presses  his  fingers  too  close  to  the 
symphysis,  or  too  high  up  toward  the  umbilicus.  The  normal  j)osition  of 
the  fundus  uteri  is  about  three  inches  above  the  upper  border  of  the 
symphysis.  By  passing  the  internal  finger  into  the  anterior  vaginal 
pouch,  and  pressing  inward  and  downward  toward  the  symphysis  with 
the  other  hand,  the  fundus  will  usually  be  found  between  the  two 
hands. 

Besides  size,  consistence,  and  outline,  the  mobility  of  the  uterine  body, 
as  influenced  by  motion  of  the  cervix  and  the  palpating  hand,  and  its  sen- 
sitiveness are  points  worthy  of  notice..  The  normal  uterus  is  exceedingly 
movable,  especially  in  the  antero-posterior  diameter.  Excessive  mobility, 
so  that  the  fundus  may  be  pressed  down  under  the  symphysis  or  into  the 
sacral  excavation,  or  an  anterior  displacement  may  be  charged  to  a  retro- 
deviation or  vice  versd,  by  a  few  simple  manipulations,  is  indicative  of  re- 
laxation of  its  supports  ;  diminished  mobihty  on  the  other  hand,  imparting 
to  the  finger  the  sensation  of  resistance,  denotes  previous  inflammatory 
thickening  or  shortening,  or  possibly  non-development,  of  its  supports. 

Normally,  the  fundus  uteri  is  not  sensitive  to  moderate  pressure ;  it 
has  a  dense,  smooth  feel.  But,  let  it  be  enlarged  and  its  surface  irregular 
through  areolar  hyperplasia  or  subinvolution,  and  the  patient  will  gener- 
ally complain  of  more  or  less  acute  pain  on  compression,  particularly  if  the 
abdominal  wall  is  rubbed  over  the  fundus. 

When  the  position,  size,  and  outline  of  the  body  and  fundus  of  the 
uterus  have  been  ascertained  by  palpation,  the  external  hand  is  moved  to 
one  side  and  in  the  same  manner  presses  the  organs  situated  in  the  lateral 
portions  of  the  pelvis  toward  the  internal  finger.  By  alternately  pressing 
downward  with  the  outer  hand,  and  upward  with  the  mternal  finger,  and 
by  rubbing  the  external  fingers  over  the  internal  one,  the  region  of  the 
soft,  obscure  broad  hgaments  is  thoroughly  searched,  and  the  normal 
ovaries  are  in  many  instances  recognized.  Indeed,  when  the  abdominal 
walls  are  thin  or  relaxed,  the  ovaries  can  almost  always  be  readily  mapped 
out  by  this  method.  When  they  are  enlarged,  or  enclosed  in  a  shell  of 
plastic  lymph,  they  are  invariably  detected  with  ease.    It  should  be  noticed 


BIMA"N"UAL   EXAMINATIOlSr.  61 

that  tlie  sensation  imparted  to  the  external  fingers  is  generally  more  vague, 
like  that  of  diffuse  resistance  ;  the  internal  finger,  against  which  the  organ 
is  pushed,  detects  its  outline,  size,  consistence,  and  mobility.  In  spare 
individuals  the  Fallopian  tubes,  ovarian  and  round  ligaments  can  occa- 
sionally be  touched  in  this  manner. 

A  firm,  immovable  body  in  the  broad  ligament,  like  a  cellulitic  deposit 
of  not  very  recent  date,  can  usually  be  enclosed  between  the  fingers  of 
both  hands,  and  its  outUne  clearly  mapped  out ;  the  same  is  the  case  with 
small  ovarian  tumors,  cysts  of  the  broad  ligament  and  tube.  In  this  way 
a  unicornite  or  bicornite  uterus  may  be  detected,  and  the  connection  of 
tumors  with  the  lateral  uterine  wall  decided  or  denied.  It  is  often  ex- 
tremely difficult  to  decide  whether  a  tumor  a^^parently  attached  to  the 
side  of  the  uterus  by  a  flat,  slender  band  is  a  subperitoneal  pediculated 
fibroid  or  a  solid  ovarian  tumor  with  its  pedicle  of  broad  ligament. 

In  large  abdominal  tumors  bimanual  examination  is  useful  in  showing 
the  connection  of  a  growth  felt  by  the  internal  finger  with  the  bulk  of  the 
tumor  ;  thus,  if  the  external  hand  pushes  the  tumor  downward,  the  im- 
pulse and  descent  is  felt  in  the  vagina,  or  if  fluctuation  is  present  the  wave 
is  detected  by  the  internal  finger,  unless,  indeed,  the  tumor  be  divided  by 
septa.  Further,  a  pelvic  tumor  may  be  raised  by  the  internal  finger,  and 
its  connection  with  the  abdominal  growth  thus  demonstrated. 

The  exercise  of  simple  and  conjoined  palpation  requires  a  vast  degree 
of  practice  and  a  delicacy  of  touch  greatly  superior  to  that  needed  for 
mere  indagation.  The  value  of  bimanual  examination  to  the  gynecologist 
and  the  results  obtained  are,  therefore,  proportionate  to  the  skill  of  the 
individual  examiner.  To  detect  a  pregnancy  of  six  weeks  solely  by  the 
slight  increase  in  size  of  the  uterine  body  ;  to  discriminate  between  a 
pediculated  subperitoneal  fibroid  of  the  uterus  and  a  small  multilocular 
ovarian  tumor  ;  to  recognize  obscure,  deep-seated  fluctuation  in  a  cellulitic 
deposit  between  the  layers  of  the  broad  ligaments  by  the  doughy,  boggy 
feel  of  the  tumor  ;  to  map  out  the  extent  of  an  intraperitoneal  exudation  ; 
to  do  all  this  with  absolute  certainty  requires  years  of  experience  and 
practice,  easy  though  it  may  seem  to  the  beginner. 

b.  Recto-abdominal;  c.  Vesico-abdominal. — The  details  of  these  methods 
are  essentially  the  same  as  those  of  combined  abdomino-vaginal  examina- 
tion. When  the  finger  is  in  the  rectum,  the  external  hand  is  chiefly  en- 
abled to  palpate  the  posterior  surface  of  the  uterus  and  broad  ligaments, 
therefore  the  ovaries,  and  retro -uterine  or  (possibly)  retrorectal  or  retro- 
peritoneal tumors.  Ketro-uterine  tumors  may  often  be  more  readily  dis- 
lodged and  grasped  from  above  by  this  method.  The  distended  sigmoid 
flexure,  or  a  high  rectal  stricture  can  scarcely  escape  detection  if  this  ex- 
amination be  made. 

The  external  hand  chiefly  serves  to  joress  toward  the  finger  in  the 
bladder  and  steady  the  fundus  and  body  of  the  uterus,  the  anterior  face  of 
the  broad,  round,  and  ovarian  ligaments,  and  the  Fallopian  tubes.  The 
ovaries,  naturally,  although  situated  on  the  posterior  surface  of  the  broad 
ligaments,  thus  become  accessible  to  the  internal  finger.     The  differential 


62 


GYIS^ECOLOGICAL    EXAMIJSTATIOISr. 


diagnosis  between  small  ovarian  cyst,  cj^st  of  the  broad  ligament,  and  hy- 
dro- or  j)yosalpinx,  is  often  to  be  made  only  by  this  method,  -which  enables 
the  examiner  to  trace  the  outlines  and  attachments  of  the  tumor  with 
almost  absolute  accuracy.  The  diagnosis  between  cyst  of  the  broad  liga- 
ment and  monocyst  of  the  ovary  i^,  indeed,  possible  usually  only  by  the 
hypodermic  needle  and  the  microsome,  and  then  not  always  with  certainty. 
The  ovoid  shape  of  fluid  accumulati]&QS  in  the  tube  may  prove  an  aid  to 
diagnosis.  The  round  ligaments  arlfethe  seat,  so  far  as  I  know,  of  only  one 
variety  of  disease,  a  fibromyoma,  wlaph  is  of  very  rare  occurrence.  Intra- 
pehdc  exudations,  extra-  or  intraperifipneal,  may  also  be  mapped  out  more 
clearly  through  the  bladder;  but  it!_  should  be  considered  whether  the 
advantage  gained  thereby  compensates  for  the  danger  of  urethral  dilata- 
tion and  vesical  palpation. 

Professor  B.  S.  Schultze,  of  Jena,  has  recently  described  a  method  of  di- 
agnosing the  attachment  and  size  of  the  pedicle  of  an  ovarian  tumor,  by 
means  of  vaginal,  rectal,  and  abdominal  palpation.  The  patient  being 
anesthetized  in  the  gluteo-dorsal  position,  he  introduces  the  index  and 
middle  fingers  into  the  rectum  along  the  posterior  surface  of  the  uterus, 
the  thumb  of  the  same  hand  into  the  vagina  in  the  same  direction  ;  the 
other  hand  presses  down  the  abdominal  walls  from  the  outside  and  seeks 
to  grasp  the  pedicle  of  the  tumor  between  it  and  the  uterus.  At  the  same 
time,  an  assistant,  standing  near  the  head  of  the  patient,  lays  both  hands 
on  her  abdomen,  presses  the  abdominal  walls  do-«Taward  as  much  as  pos- 
sible, and  then  alternately  lifts  the  tumor  up  against  the  thorax  and 
drops  it,  also  drawing  it  to  one  side  or  the  other.  The  fingers  in  the  rec- 
tum, vagina,  and  on  the  abdominal  walls  feeling  altogether  cannot  fail  to 
recognize  the  size  and  attachments  of  the  tumor  to  the  uterus  or  its 
adnexa. 

F.  Digital  Eveesion  of  the  Rectum. 

'^i\'lien  a  patient  complains  of  j^ainful  defecation,  of  bloody,  mucous,  or 
puinlent  discharge  from  the  anus,  or  of  hemorrhoids,  it  is  advisable  to 


Fig.  22.— Dicrital  Eversion  of  Rectum  (P.  F.  M.). 


inspect  as  much  as  can  be  readily  exposed  of  the  rectum.  A  simple, 
rapid,  and  comparatively  j)ainless  method  of  exposing  to  view  the  lower 
two  to  three  inches  of  the  rectal  mucous  membrane  is  to  introduce  one  or 


FOKMAL    POSITION    OF    UTERUS. 


63 


two  fingers  into  the  vagina  when  the  patient  is  on  her  side,  and  attempt 
to  press  the  tips  of  these  fingers  out  of  the  anus.  In  this  manner  the 
mucous  membrane  of  a  portion  of  the  anterior  wall  of  the  rectum  and  the 
edge  of  the  sphincter  become  visible,  and  a  fissure,  ulcer,  hemorrhoid,  or 
a  catarrhal  hyperemia  of  the  mucosa  are  readily  detected.  The  posterior 
wall  of  the  rectum  cannot  be  seen  by  this  plan,  and  but  a  very  imperfect 
glimpse  of  it  may  be  obtained  by  moderately  dilating  the  anus  with  two 
fingers.     For  more  complete  inspection  specula  are  required. 


It  may  be  appropriate  here,  at  the  close  of  the  section  on  non-instru- 
mental diagnosis,  to  say  a  few  words  regarding  the  normal  position  of  the 
uterus.  Strange  as  it  seems,  this  question,  apparently  so  easy  of  solution, 
still  agitates  the  gynecological  mind,  and  there  are  probably  no  two  text- 
books or  monographs  on  gynecology  or  anatomy  in  which  the  author  has 
endeavored  to  advance  his  own  original  views  on  this  subject,  which  give 


Pig.  23. — Backward  Displacement  of  TJtems  by  Distended  Bladder  (P.  P.  M.). 


the  same  representation  of  the  normal  position  of  the  uterus  and  its  ad- 
nexa.  Nearly  all  show  it  slightly  anteverted,  but  some  make  it  anteflexed, 
others  antecurved,  and  others  straight.  And  all  call  their  diagrams  "  the 
normal  position  of  the  uterus."  The  best  of  these  views  are  those  of  Kohl- 
rausch,  modified  by  Spiegelberg,  Hodge,  Sims,  Thomas,  etc.  But  none  of 
these  authors  convey  to  the  reader  the  impression  that  this  position  of  the 
uterus  is  a  variable  one.  Only  recently  have  Schultze  and  Schroeder  in 
Germany  (whose  opinions  differ),  Hach  in  Russia,  and  Van  de  Warker  in 
this  country  defined  the  subject  more  clearly  and  shown  by  experiments 
that  the  normal  position  of  the  uterus  is  a  movable  one.     The  shape  of  the 


64 


GYISTECOLOGICAL    EXAMIlSTATIOlSr. 


uterus  is  slightly  antecurved  (not  anteverted  or  anteflexed),  its  axis  almost 
corresponding  to  that  of  the  superior  pelvic  strait  (see  Fig.  27 ;  I  think  the 
position  given  by  Van  de  Warker  in  his  article  in  the  Am.  Jour.  ObsL,  for 

July,  1878,  decidedly  too  much 
anteverted,  even  with  an  emj^ty 
.-'""•  >^       bladder),  its  angle  with  the  va- 
2     \    gina  measuring  about  155°.   (See 
;    Fig.  14.)     But  this  position  of 
,-'     the  uterus  is  subject  to  constant 
variations.     In   accordance  with 
,-•■'  the  degree  of  distention  of  the 

urinary  bladder,  the  body  and 
fundus  of  the  uterus  are  moved 
backward,  and  this  retrogression 
is  increased  if  intra-abdominal 
IDresstu-e  be  diminished,  as  in  the 
recumbent  position.  (Van  de 
Warker  says,  loc.  cit.,  "Between 
the  positions  of  the  uterus  in  an 
empty  and  in  a  full  state  of  the 
bladder  there  is  a  difference  of 
20=  to  30°.")     To  a  slighter  de- 

FiG   24.— Degrees  of  Normal  Mobility  of  the  Uterus.     The     o-ree  an  OVerdisteudcd  rCctum  wiU 
solid  outline  indicates  the  average  position  (P.  F.  M.). 

press  the  fundus  forward.  Witli 
every  variation  in  intra-abdominal  pressure  during  inspiration  and  expira- 
tion and  voluntary  motions  and  positions  of  the  body,  the  fundus  and 
body  of  the  uterus  vibrate  back  and  forth,  hke  a  pendulum,  with  its  pivot 
at  the  reflection  of  the  vagina  on  the  cervix.  It 
thus  follows  that  we  have  several  normal  positions 
of  the  uterus,  which  ,1  have  been  in  the  habit  of 
considering  as  the  first  degree  of  normal  ante- 
displacement,  and  first,  second,  and  third  degrees 
of  normal  retro-displacement.  Their  extent  is 
best  described  by  the  accomjoanying  diagram.  V 

As  regards  the  average  normal  position  of  the     ^ig.  25.— utero-vaginai  Axis  in 

,  .  Kormal  Kelation  of  Organs,    v,  va- 

uterus,my  experience  leads  me  to  adopt  the  view  gina;  u,  uterus  (p.  f.  m.;. 
of  the  late  Professor  E.  Martin,  of  Berlin,  who 

held  that  with  the  woman  in  the  recumbent  posi-  \ " 

tion,  the  examining  finger  is  unable  to  touch  the  -pio.  26.— utero-vaginai  Axis  in 
body  of  the  uterus  before  or  behind  the  cervix  ,^Ta°ifatu,  uLms  (p!'f.  mT'"' 
if  the  uterus  is  normally  situated  ;  as  soon  as  the 

vaginal  finger  can  feel,  be  it  ever  so  little,  of  the  uterine  body  through 
the  anterior  or  posterior  vaginal  pouch,  the  uterus  must  be  considered  to 
be  proportionately  ante-  or  retrodisplaced.  In  the  erect  posture  the  body 
of  the  uterus  will  naturally  tilt  forward  a  little,  and  may  be  indistinctly 
felt  through  the  anterior  vaginal  wall.  Figs.  1  and  7  seem  to  me  to  show 
the  relations  pretty  correctly. 


NOEMAL    POSITION    OF    UTERUS. 


05 


It  should  be  remembered  that  the  normal  relation  of  the  axis  of  the 
vaginal  canal  is  nearly  at  a  right  angle  with  that  of  the  uterine  canal  (Fig. 
25).  When  the  woman  as- 
sumes the  recumbent  position 
this  relation  is  maintained  ; 
but  it  should  be  borne  in  mind 
that  the  fundus  uteri  then  al- 
ways remains  sHghtly  above 
the  promontory  of  the  sacrum. 
Let  the  fundus  sink  below  the 
promontory,  and  the  cervix 
therefore  point  toward  the  va- 
ginal outlet — that  is,  the  vagi- 
nal and  uterine  canals  be  in 
the  same,  or  nearly  the  same, 
axis  (Fig.  26) — we  have  retro- 
version in  the  first  degree, 
whether  the  woman  be  in  the 
erect  or  recumbent  posture. 
The  relations  between  vagina 
and  uterus  and  between  the 
fundus  uteri  and  the  promon- 
tory of  the  sacrum  are  the 
guiding  points  in  determining 
posterior  displacement  of  the 
uterus. 

The  relations  of  the  various 
axes  of  the  pelvic  canal,  vagina, 
and  uterus  to  the  perpendicu- 
lar axis  of  the  whole  body  are 
shown  in  Fig.  27. 

The  third  degree  of  normal 
posterior  mobility  of  the  ute- 
rus   must     thus     correspond 
about  to  the  normal  position 
of  the  uterus  in  the  recumbent 
posture,  and  the  first  degree 
of  anterior  mobility  might  in- 
dicate the  physiological  forward  inclination  of  the  organ  in  the  erect  post- 
ure.     A  more  marked  anterior   inclination,  or  even  a  slight  flexion,  as 
some  authors  assert,  I  for  my  part  have  certainly  never  been  able  to  accept 
as  the  healthy,  natural  position  of  the  uterus. 
5 


P*" 


Fig.  27. — Section  of  whole  Body  showing  Relation  of  Pelvic 
Organs  to  the  Perpendicular  Axis  of  the  Body.  C,  A,  corpo- 
real axis ;  V,  A,  vaginal  axis ;  U,  A,  uterine  axis ;  P,  F,  pelvic 
floor;  P,  I,  pelvic  inlet  (P.  F.  M.). 


Q6  GYNECOLOGICAL    EXAMINATION. 

6.  Examination  by  Means  of  Insteuments. 

Dinvfectioji  of  Instruments. — Before  proceeding  to  enumerate  and  de- 
scribe in  detail  all  the  instruments  in  use  for  the  diagnosis  and  treatment 
of  the  diseases  of  the  female  genital  organs,  it  may  be  well  to  make  a  few 
general  remarks  as  to  the  precautions  to  be  observed  in  employing  them. 
Such  special  accidents  as  may  arise  from  certain  instruments  will  be  de- 
scribed in  their  respective  sections,  but  there  is  one  great  and  universal 
source  of  danger  which  is  very  slightly  touched  upon  in  the  text-books, 
and  which,  I  think,  is  very  generally  oveiiooked  by  the  profession,  viz.  : 
want  of  cleanliness  of  instruments.  When  we  consider  how  easily  septic  or 
infectious  matter  may  be  transmitted,  not  only  on  the  fingers,  but  on  sj)ecula, 
sounds,  tenacula,  knives,  forceps,  etc.,  from  one  patient  to  another,  it  is 
evident  that  the  most  scrupulous  cleanliness  should  be  observed  as  regards 
the  instruments  used  in  an  examination  or  operation  before  again  em- 
ploying them  on  another  patient.  And  as  it  is  exceedingly  difficult  to 
thoroughly  remove  all  secretions  from  the  complex  instruments  referred  to, 
the  only  safe  way  is  to  steep  them  after  each  examination  in  boiling  water, 
then  lay  them  for  a  few  moments  in  a  five  per  cent,  solution  of  carbolic 
acid,  and  finally  leave  them  in  a  one  per  cent,  solution  of  the  same  disin- 
fectant during  the  examination.  I  always  make  it  a  practice  to  remove  all 
mucus  or  other  excretion  from  the  forceps,  tenaculum,  or  sound,  by  dipping 
it  in  the  basin  of  warm  carbolized  water  in  which  the  metal  instmments 
to  be  used  are  kept  at  my  right  hand  during  every  examination.  Besides, 
I  think  it  a  good  plan  to  anoint  speculum,  sound,  and  tenaculum  with  two 
per  cent,  carbolized  vaseline.  After  an  operation,  the  complex  scissors  and 
forceps  used  should  be  separated,  each  blade  carefully  washed,  carbolized, 
and  polished  until  every  sign  of  discoloration  disappears.  Carbolic  acid, 
it  is  true,  sj)ots  the  bright  surface  of  steel  instruments,  and  thereby  annoys 
the  neat  surgeon.  But  carbolic  spots  are  a  sign  of  disinfection  and  clean- 
liness, and  consequent  safety  from  septic  infection  ;  and  herein  must  lie 
the  consolation  for  the  tarnished  instruments. 

If  it  were  feasible,  a  mild  carbolized  vaginal  injection  before  every 
examination  would  be  advisable.  Before  an  operation  on  the  intravaginal 
organs  it  is  always  possible  to  order  such  a  precaution,  and  in  case  of  need 
the  vagina  may  be  mopped  out  by  the  operator  with  a  stronger  (five  per 
cent.)  solution  before  proceeding  to  operate. 

While  the  question  of  septic  infection  through  floating  or  otherwise  trans- 
mitted germs  and  the  possibility  of  killing  these  germs  by  carbolic  acid,  must 
still  be  considered  unsettled  (Lawson  Tait  omits  carbolic  acid  entirely  in  his 
operations),  one  thing  is  certain,  viz.,  that  by  the  careful  and  frequent  wash- 
ing and  immersion  of  oiu'  instruments  in  carbolized  water,  we  insure  their  ab- 
solute cleanliness,  and  that  is  the  main  point.  Hence,  whether  the  carbolic  be 
indispensable  to  safety  or  not,  I  recommend  and  use  it  as  a  disinfectant. 

As  regards  the  disinfection  of  the  hands,  I  find  tar-soap  applied  with  a 
brush  very  pleasant  and  effectual.  If  desired,  a  one-tenth  per  cent,  solu- 
tion of  thymol  may  be  poured  over  the  bands. 


EXAMINATION    BY    MEANS    OE    INSTRUMENTS.  67 

While  what  has  here  been  said  applies  to  every  vagino-uterine  exami- 
nation or  operation,  no  matter  how  trivial,  in  larger  operations,  such  as 
ovariotomy  and  hysterectomy,  where  the  enormous  absorbing  surface  of 
the  peritoneum  is  exposed,  the  above  precautions  will  naturally  be  vastly 
intensified. 

Particularly  should  sponges  be  cleansed,  boiled,  and  disinfected  with 
scrupulous  care,  and  if  the  least  doubt  exists  as  to  the  possibility  of 
thoroughly  cleaning  them,  they  should  be  thrown  away.  I  always  have 
my  sponges  boiled  in  five  per  cent,  carbolized  water,  then  washed  in  clean 
water,  and  again  soaked  in  five  per  cent,  carbolic  and  squeezed  dry  before 
each  operation.  The  difficulty  of  thus  cleaning  s^Donges  is  the  chief  rea- 
son why  I  do  not  use  them  during  ordinary  examinations  to  cleanse  the 
vagina  and  cervix,  but  prefer  absorbent  cotton,  which  is  tkrown  away  when 
soiled.  Besides,  the  character  and  color  of  the  secretions  is  better  seen 
on  the  white  cotton  than  on  the  brown  sponges. 

The  sponges  used  during  operations  (both  small  sponges  for  mopping 
up  blood,  and  large  flat  ones  for  protecting  the  intestines  and  covering 
the  abdominal  incision  during  laparotomy),  are  prepared  for  each  opera- 
tion after  the  following  method  : 

1.  They  are  freed  from  sand  and  other  impurities  by  thorough  beating. 

2.  They  are  immersed  in  a  two  to  three  per  cent,  dilution  of  pure 
hydrochloric  acid,  for  from  ten  to  fifteen  minutes,  and  are  then  washed 
until  the  water  no  longer  shows  an  acid  reaction. 

3.  They  are  thoroughly  immersed  in  a  one  per  cent,  solution  of  per- 
manganate of  potash,  well  washed  with  pure  water,  and  squeezed  dry. 

4.  They  are  again  immersed  in  a  bleaching  fluid  composed  of  one 
ounce  each  of  hyposulphite  of  soda  and  hydrochloric  acid  in  one  quart  of 
water  (which  must  always  be  prepared  fresh),  are  again  thoroughly  washed 
in  pure  water,  soaked  in  a  two  per  cent,  solution  of  carboHc  acid  containing 
two  ounces  of  glycerine  to  the  quart,  squeezed  dry,  and  preserved  in  well- 
stoppered  glass  jars. 

The  small  fragments  of  sponges  used  on  sponge-holders  in  cerrix  and 
perineum  operations  can  either  be  thi'own  away  after  each  operation  (the 
better  way)  or  be  thoroughly  boiled  in  a  ten  per  cent,  solution  of  carbolic 
acid,  soaked  in  the  solution  of  glycerine  and  carbolic  acid  above  men- 
tioned, and  preserved  in  jars.  As  a  rule,  all  chance  of  the  transmission  of 
infectious  matter  after  operations  in  which  only  blood  is  inopped  up  is 
prevented  by  the  latter  treatment. 

Since  the  introduction  of  the  unquestionably  much  more  powerful 
germicide,  corrosive  subhmate,  I  have  substituted  it  for  carbohc  acid 
during  operations,  soaking  sponges  in  a  one  to  one  thousand  parts  solu- 
tion for  some  time  before  the  operation,  and  then  washing  the  sponges 
during  the  operation  in  a  one  to  two  thousand  solution.  The  instruments 
are  so  much  tarnished  by  keeping  them  in  a  corrosive  subhmate  solution, 
and  the  operator's  hands  in  time  become  so  affected  by  it,  that  I  have  adopted 
the  practice  of  keeping  my  instruments  thoroughly  cleaned  and  poHshed, 
and  washing  my  hands  during  an  operation  in  sol.  thymol  or  listerine. 


68 


GYNECOLOGICAL    EXAMHS-ATIOjST. 


A.  Examination  of  the   Urethra  and  Bladder   by  Sound,    Catheter,   or 

Speculum. 

Indications. — When  a  patient  complains  of  painful,  too  frequent,  or  too 
scanty  micturition,  or  when  the  finger  in  the  vagina  detects  an  unusual 
sensitiveness  of  the  urethral  body  or  vesical  base,  it  may  be  desirable  to 
exj)lore  the  urethra  and  bladder  by  means  of  instruments  or  the  finger. 
Conditions  of  the  urethra  producing  the  above  symptoms  are  :  caruncles, 
fissure,  ulceration,  simple  spasmodic  contraction  of  the  circular  fibres  at 
the  vesical  neck  ;  of  the  bladder :  acute  and  chronic  cystitis,  stone,  neo- 
plasms (villous  cancer). 

Counterindications. — To  the  gentle  introduction  of  a  sound  or  cathe- 
ter into  the  urethro-vesical  cavity  there  can  scarcely  be  an  objection  ;  the 
use  of  a  urethral  sjDeculum  or  endoscope  necessitating  previous  dilatation 
of  the  urethra  would  be  counteidndicated  by  the  same  conditions  inter- 
fering with  mere  dilatation  and  given  under  Vesical  Touch,  viz.,  excessive 
fragihty  of  the  ui-ethi-al  wall  and  recent  inflammation  of  the  pelvic  tis- 
sues. 

Method. — A  uterine  sound,  ordinary  male  or  female  metaUic  or  elastic 
catheter,  can  be  introduced  into  the  normal  urethra  and  thence  into  the 


Fig.  28. — Skene's  Urethral  Endoscope. 

bladder  with  no  difficulty  and  very  httle  pain.  No  obstruction  is  ordi- 
narily met  with  at  any  point  of  the  canal,  and  pain  is  exjoerienced  only  at 
the  junction  of  urethra  and  bladder,  and  when  the  instrument  strikes 
against  the  opposite  wall  of  the  bladder.  If  the  parts  are  inflamed,  if 
urethritis  and  cystitis  are  present,  the  maneuvre  will  be  painful,  the  more 
so  the  more  acute  the  inflammation.  If  a  tender  point  has  been  detected 
the  exact  spot  may  be  more  accurately  examined  by  pressing  the  finger  in 
the  vagina  against  the  intravesical  instrument.  Tenderness  at  the  vesical 
neck  may  mean  a  fissure  or  ulceration  of  that  spot.  If  bleeding  follows 
the  exploration,  there  may  be  intra-urethral  vascular  growths  or  caruncles, 
or  fissures,  or  ulceration  ;  or  an  abrasion  of  the  vesical  mucous  membrane 
may  be  the  seat  of  the  hemorrhage. 

Where  absence  of  the  uterus  or  ovaries  is  suspected,  the  tissues  above 
the  vaginal  pouch  may  be  searched  with  tolerable  accuracy  between  the 


examijstatiox  by  means  of  instruments.  69 

jBnger  in  the  rectum  and  a  catheter  or  sound  in  the  bladder.  This  manip- 
ulation is  particularly  valuable  in  susjDected  congenital  absence  of  the 
organs  named,  and  in  inversion  of  the  uterus. 

When  it  ajDpears  desirable  to  insjDect  the  mucous  surface  of  the  urethra, 
the  expansion  of  the  canal  by  any  dilating  instrument,  such  as  ordinary, 
dressing-forceps  or  uterine  dilator,  will  often  suffice.  Thus  an  ordinary 
hairpin,  with  its  points  fixed  in  a  cork,  may  dilate  the  meatus  sufficiently 
to  give  a  view  of  the  first  half  of  the  canal.  Special  instruments  for  the 
purpose  have  been  devised  by  Barnes,  Skene,  and  recently  by  Di-.  Alex.  W. 
Stein,  of  New  York.  Barnes'  instrument  acts  on  the  principle  of  a  tubular 
speculum,  with  a  slit  along  nearly  its  whole  length,  for  the  purpose  of 
catching  a  caruncle,  and  presenting  it  ready  for  removal ;  Stein's  specidum 
is  a  simple  tubular  dilator,  which  is  to  be  gradually  pressed  inward  until 
it  passes  the  neck  of  the  bladder,  and  then  used  as  an  endoscope  for  that 
organ,  the  different  sections  of  the  mucous  membi'ane  being  one  after  the 
other  brought  into  its  focus.  It  is  a  very  serviceable  instrument,  decidedly 
superior  to  that  of  Barnes,  both  for  inspection  and  operation.  A  useful 
ui'ethral  dilator  is  the  ordinary  nasal  speculum.  Besides  the  speculum 
shown  in  the  cut.  Dr.  Skene  has  devised  an  endoscope  for  the  urethra  and 
bladder,  which  consists  of  a  glass  tube,  precisely  like  an  ordinary  test-tube, 
varying  in  size  according  as  it  is  to  be  used  merely  for  urethral  exploration, 
or  is  to  be  passed  into  the  bladder,  and  of  a  section  of  a  cylinder  made 
black  and  having  a  mirror  at- 
tached at  rather  an  acute  angle 
at  its  distal  extremity.  The 
glass  tube  is  introduced  first, 

into  it  the  section  with  the  mir-  ^'^-  29.-Skene's  urethral  Speculnm. 

ror,  and  with  an  ordinary  forehead-mirror  light  is  thrown  on  the  mirror 
in  the  tube  ;  the  shifting  of  the  tube-mirror,  forward  and  backward  or 
from  side  to  side,  exposes  the  various  parts  of  the  lining  membrane  of 
the  bladder.  The  smaller  size  may  possibly  be  used  on  the  unprepared 
urethra,  but,  as  a  rule,  to  avoid  breaking  the  glass  tube,  and  indeed  to 
gain  a  view  which  will  be  of  any  use  at  all,  it  is  advisable  to  dilate  the 
urethra,  at  least  to  the  diameter  of  the  little  finger,  before  introducing  the 
endoscope.  Dr.  Skene  says  that  the  pressure  of  the  tube  will  give  the 
mucous  membrane  a  paler  color  than  normal,  but  that  this  only  serves  to 
bring  out  more  forcibly  the  inflamed  portions.  By  pushing  up  the  bladder 
walls  from  the  vagina  below,  and  the  abdominal  surface  above,  the  whole 
interior  of  the  organ  can  be  brought  successively  within  the  focus  of  the 
endoscope. 

An  improvement  on  this  endoscopic  insj)ection  of  the  collapsed  blad- 
der has  been  introduced  by  Rutenberg,  who  has  made  a  very  thorough 
study  of  this  subject.  He  found  that  the  walls  of  the  coUapsed  bladder 
prolapsed  against  the  lumen  of  the  endoscope,  and  interfered  with  vision. 
He  therefore  distended  the  organ  with  water,  which  was  too  opaque  and 
dimmed  the  mirror,  and  then  with  air,  which  is  pumped  into  the  bladder 
through  the  tube  shown  at  a  in  the  adjoining  cut.     The  speculum  is  made 


70 


GYNAECOLOGICAL    EXAMINATI0T7. 


of  German  silver,  of  equal  size  at  both  ends,  and  of  19  mm.  inside  diam- 
eter ;  on  tlais  speculum  (of  which  there  are  various  sizes)  is  screwed  the 


•^ 


top  mth  piston-rod  for  the  miirror  shown  in  the 
cut.  At  6  is  a  glass  window,  and  at  a  the  tube 
to  which  the  rubber  tubing  for  the  injection  of 
air  by  a  balloon  is  attached.  The  distention  of 
the  bladder  is  always  painful ;  the  examination 
should,  therefore,  always  be  made  under  an  an- 
esthetic, even  when  previous  dilatation  of  the 
urethra  is  unnecessary.  The  bladder  is  first 
emptied  of  uiine,  and  the  sjDeculum  then  intro- 
duced into  the  dilated  urethra  in  the  gluteo-dorsal 
position,  the  top  is  screwed  on,  and  the  bladder 
filled  with  air  from  the  balloon  by  one  assistant, 
while  the  other  holds  the  lamp  for  reflection  over 
the  patient's  pubis.  The  hght  is  thrown  into  the 
bladder  with  an  ordinaiy  concave  mirror.  The 
endoscopic  mirror  is  needed  for  the  insjDection 
of  all  parts  of  the  bladder  except  the  posterior 
and  posterior  inferior  j)ortion.  The  details  as 
regards  warming  the  mirror  pectiliar  to  a  laryn- 
goscopic  examination  also  apply  here.  The  dis- 
tention of  the  bladder  was  found  by  Eutenberg 
to  change  the  color  of  its  mucous  lining  from 
dirty  grayish  red  to  hght  red,  and  to  expose  all 
the  fine  ramifications  of  vessels,  and  even  fasci- 
cuh  of  muscles.  The  mouths  of  the  ureters 
were  never  visible  except  after  they  were  found 
with  the  sound.  Winckel,  whose  experience 
in  this  branch  has  been  large,  pronounces 
Eutenberg's  method  to  be  entirely  devoid  of 
danger  as  regards  insufilation  of  air  into  the 
ureters,  and  in  any  other  sense,  and  to  be  a  very 
valuable  contribution  to  the  diagnosis  of  blad- 
der affections.  He  found  the  light  of  an  ordinary 
petroleum  argand  burner  placed  over  the  pubis 
quite  sufficient  for  purjDoses  of  reflection. 

The  dii'ect  application  of  medicinal  agents  to 
diseased  portions  of  the  bladder  mucosa  is  also 
rendered  feasible  through  Eutenberg's  endo- 
scope. 

The  field  of  vision  afforded  by  all  these  spec- 
ula and  endoscopes  for  the  urethra  and  bladder 
naturally  is  but  a  small  one,  corresponding  with  the  limited  dilatabihty  of 
the  urethral  canal,  and  their  practical  utility  therefore  in  no  way  equals 
that  of  specula  for  other  passages.  Still,  without  them  the  diagnosis  of 
m-ethi-al  and  vesical  disease  may  often  be  entirely  impossible. 


Fig.  so. — ^Rutenberg's  Endoscope. 


EXAMHSTATION"    BY    MEANS    OF    INSTRUMENTS. 


71 


The  late  Professor  Simon,  of  Heidelberg,  practised  and  taught  the  intro- 
duction of  sounds  through  the  dilated  urethra  into  the  mouths  of  the  ure- 
ters, for  the  purpose  of  detecting  abnormal  conditions  of  these  ducts.  What 
was  undoubtedly  possible  to  his  acute  touch  will  scarcely  be  feasible  for  us 
without  an  amount  of  practice  entirely  out  of  proportion  to  the  benefit  to 
be  derived  from  the  operation.  A  practitioner  so  well  versed  in  vesical 
disorders  as  Winckel,  says  that  "  notwithstanding  gi-eat  perseverance  he 
never  was  so  fortunate  as  to  find  the  canal  (of  the  ui-eter)  with  the  sound." 
For  completeness'  sake  I  will  merely  say  that  the  finger  passed  through 
the  dilated  urethra  detects  the  nodule  marking  each  ureteral  mouth  about 


BGt. 


jisr 


TrL 


Fig.  31.— The  Finger  in  the  Bladder  touching  the  Mouths  of  the  TTretors  (Winckel).  BCfr.,  a  a  a, 
base  of  bladder ;  6  &,  mouths  of  ureters  ;  T/'i,  interureteric  ligament :  trigonum  vesicae;  /iBW,  posterior 
wall  of  bladder. 

one  inch  from  the  sharp  vesical  neck  on  the  so-called  interureteric  liga- 
ment about  1.25  to  1.60  ctm.  each  side  of  the  median  line.  If  the  nodule 
is  distinctly  felt,  Simon  claims  that  a  long,  blunt-pointed  sound  or  catheter 
can  be  passed  along  the  finger  into  the  slit,  and  by  pressing  the  handle 
of  the  sound  toward  the  opposite  ramus  of  the  pubic  arch,  into  the  ureter, 
even  up  to  the  renal  pehds.  Simon  succeeded  seventeen  times  in  eleven 
women  in  this  maneuvre,  without  injury  to  the  patient.  He  advocated 
it  for  the  diagnosis  of  ureteral  and  renal  calculi,  ureteral  stricture,  and 
the  cure  of  hydronephrosis.  The  cases  in  which  it  will  be  indicated  are 
obviously  rare,  and  the  evident  danger  of  inflicting  injury  will  suffice  to 
prevent  the  too  frequent  employment  of  this  exceedingly  difficidt  ma- 
neuvre. 


72  GYNECOLOGICAL    EXAMINATION". 

B.  Examination  of  the  Vagina,  Cervix,  and  External  Os  with  the  Speculum. 

Indications. — Not  every  patient  wlio  Las  been  subjected  to  a  digital 
examination  of  her  genital  organs  need  necessarily  be  examined  with  the 
speculum.  The  finger  and  the  sound  may  have  told  us  aU  we  can  exjDCct 
to  find  in  the  case,  and  at  aU  events  they  have  shown  us  the  absence  of  a 
necessity  for  further  exjDloration.  Besides,  there  are  various  conditions, 
hereafter  to  be  enumerated,  which  counterindicate  a  specular  examina- 
tion. But  I  think  myself  justified  in  laying  down  the  rule,  that  every 
patient  who  comes  to  us  for  a  Jirst  examination  and  a  diagnosis  desers^es  to 
have  her  case  investigated  by  every  proper  means  at  our  disposal,  and  that 
we  should  omit  no  measiu'e  which  may  give  us  the  fullest  possible  insight 
into  her  case,  and  her,  therefore,  the  best  chance  for  cure.  I  therefore 
make  it  a  practice  to  examine  every  patient  who  comes  to  me  for  diagnosis 
and  treatment  the  first  time,  not  only  with  the  finger  and  the  sound, 
but  also  subsequently  with  the  speculum,  and  have  frequently  had  cause 
to  commend,  seldom  to  regret,  this  practice.  Of  course,  the  presence  of  a 
hymen,  and  other  counterindications  wiU  modify  this  rule  to  some  extent, 
both  as  regards  sound  and  sjDeculum. 

Special  indications  for  a  specular  examination  at  any  time  ai'e  the  detec- 
tion by  the  finger  of  conditions  of  the  vagina  or  cervix  which  require  to  be 
verified  or  corrected  by  the  eye,  such  as  granular  vaginitis,  laceration, 
erosiou,  ulceration,  folhcular  or  cystic  hyperplasia,  carcinoma  of  the 
cervix  ;  patulousness  of  and  discharge  from  the  cervix  ;  a  leucorrheal  or 
sanguineous  discharge,  the  origin  of  which,  from  vagina,  cer rix,  endo- 
metrium, or  perhaps  pelvic  abscess  opening  into  the  vagina,  only  ocular 
inspection  can  decide.  Thus,  a  soft  pulpy  condition  of  the  cervix  wiK 
often  be  seen  through  a  speculum  to  be  due  to  cervical  hyperemia  and 
erosion,  or  the  bloody  tinge  on  the  examining  finger  is  shown  on  specular 
examination  to  come  from  a  catai'rhal  erosion  of  the  cervix,  and  the  origin 
of  the  supposed  jDrolonged  menstrual  flow  is  thereby  explained.  Ee- 
cently,  in  a  case  of  profuse,  offensive,  purulent  vaginal  discharge  in  an 
old  lady,  what  I  first  supposed  to  be  a  senile  vaginitis,  jDroved,  through  the 
speculiun  (introduced  for  the  pui'jDose  of  inserting  medicated  tamjDons)  to 
be  a  large  pelvic  abscess  opening  into  the  posterior  vaginal  pouch  by  a 
small  opening  ;  the  filling  of  the  vagina  with  purulent  fluid  in  gushes 
whenever  the  Sims  was  pressed  tightly  behind  the  cei-rix  led  to  the  sus- 
picion of  the  true  nature  of  the  case  and  the  discovery  of  the  at  first 
invisible  opening  into  the  abscess. 

Counterindications. — The  objections  to  a  specular  examination  are, 
1.  The  needlessness  of  such  an  exjoloration,  as  eridenced  by  prerious  inda- 
gation.  2.  The  presence  of  a  hymen  or  other  obstacle  to  the  introduction 
of  the  instrument  (such  as  ulceration,  acute  inflammatiou,  stricture  or 
atresia  of  the  vagina).  3.  Excessive  sensitiveness  of  the  "\ailva  (vaginismus) 
or  vagina,  or  nervousness  of  the  patient.  4.  The  probability  of  doing  harm 
by  the  examination,  as  of  exciting  fi'esh  hemorrhage  or  interfering  -^ith 
union  after  plastic  operations. 


EXAMIISTATION    WITH   THE    SPECULUM.  73 

That  none  of  these  objections,  except  absohite  physical  impossibility 
of  introducing  the  siDCCulum,  are  positive  obstacles  to  such  an  examina- 
tion is  obvious,  when  the  necessity  therefor  becomes  imperative. 

Varieties  of  specula,  and  methods  of  using  them. — There  are  three 
chief  varieties  of  vaginal  specula  :  1,  cylindrical  or  tubular  ;  2,  bi-,  tri-,  or 
quadri- valvular,  or  expanding  specula  ;  and  3,  the  duck-bill  or  Sims'  specu- 
lum. Of  all  these  varieties  there  exist  numerous  modifications  and  com- 
binations, the  number  of  which  is  legion,  and  the  mechanism  often  so 
complicated,  or  differing  so  little  fi'om  the  conventional  shape  as  to  be 
either  indescribable  or  unwoi'thy  of  description.  As  every  "risin"-" 
gynecologist  seems  to  consider  it  a  duty  which  he  owes  to  the  specialty 
to  invent  either  a  speculum  or  a  pessary,  I  shall  be  compelled  to  confine 
myself  to  the  description  of  such  instruments  as  have  been  tested  and 
found  pre-eminently  useful  and  jDractical  over  their  competitors,  and  to 
refer  my  readers  for  a  full  list  to  the  catalogues  of  the  instrument- 
makers. 

1.  The  Cylindrical  Speculum. — The  most  popular,  because  the  most 
convenient,  are  the  cylindrical  or  tubular  s^Decula.  They  are  manufact- 
ured of  various  substances — wood,  metal,  glass,  gutta-percha,  hard  rub- 
ber, horn.  The  materials  most  ordinarily  used  are  glass,  hard  rubber,  and 
metal.  Those  of  glass  and  metal  give  the  best  light,  but  are  relatively 
more  expensive  than  the  hard-rubber  tubes,  the  glass  because  they  are  so 
fragile,  and  the  metal  (brass  or  nickel-j)late)  because  they  soon  tarnish  and 
become  dim  and  require  polishing  or  rej)lating. 

The  specula  of  milk-glass  devised  by  Mayer,  of  Berlin,  are  certainly 
more  practical  than  those  of  Fergusson,  which  are  composed  of  clear  glass 
covered  by  tinfoil  and  a  thick  coating  of  polished  rubber  enamel.  The 
milk-glass  specula  readily  nick  at  the  edge,  it  is  true,  and  are  then  useless, 
but  the  enamel  covering  of  the  Fergusson  chips  off  at  the  vaginal  edge  at 
the  slightest  violence  and  becomes  bdttle  at  a  low  temj^erature.  Besides, 
the  excessive  refraction  of  the  Fergusson  is  unnecessary,  and  the  light 
given  by  the  milk-glass  c[uite  sufiicient.  While  the  glass  specula  are  not 
aftected  by  the  contact  of  any  medicinal  agent,  even  the  strongest  acids, 
the  metal  instruments  do  not  permit  the  use  of  any,  even  the  mildest 
caustic,  such  as  a  solution  of  nitrate  of  silver,  or  tincture  of  iodine.  Neither 
of  these  materials,  moreover,  allows  the  contact  of  heat,  as  the  actual  or 
thermo-cautery,  for  more  than  a  fcAv  seconds,  the  glass  being  liable  to 
crack,  and  the  metal  to  become  hot.  The  most  practical  tubular  specula  are 
undoubtedly  those  of  hard  rubber,  which  are  light,  durable,  and  relatively 
inexpensive.  I  have  a  set  which  I  bought  at  Leiter's,  in  Vienna,  fourteen 
years  ago,  and  have  had  in  constant  use  since,  wherever  a  tubular  si^eculum 
was  indicated,  and  they  are  still  as  good  as  new.  This  set  consists  of  five 
specula,  ranging  in  diameter  from  f "  to  If",  and  in  length,  from  4f "  (the 
smallest)  to  5^''  ;  measuring  from  the  expanded  flange.  They  sUde  one 
into  the  othei-,  being  kept  together  by  a  cap,  and  are  therefore  exceedingly 
portable.  They  are  not  affected  by  any  agent,  or  by  heat,  except,  perhaps, 
a  slight  superficial  discoloration  ;  they  are  not  fragile,  and  do  not  chip. 


74 


GYNECOLOGICAL    EXAMIT^rATIOIT. 


The  only  objection  to  them  is  that  their  dark  surface  does  not  reflect  the 
light  as  well  as  could  be  desired,  particularly  on  a  gloomy  day,  and 
■when  the  smaller  sizes  are  used.  By  means  of  a  simple  laryngoscopic 
head  mirror  or  reflector  (to  be  described  hereafter)  this  objection  may  be 
overcome, 

I  have  recently  been  shown  by  Mr,  Philip  H.  Schmidt,  instrument- 
maker,  of  this  city,  a  set  of  these  hard-rubber  specula,  lined  with  nickel- 
plated  brass  and  thus  giving  an  excellent  reflection.  The  objection  to  all 
metal  specula,  of  tarnishing,  applies  to  them,  also,  but  the  occasional  cost 
of  replating  is  but  trifling. 

Eecently  I  have  been  shown  a  set  of  three  tubular  specula  made  of 
celluloid.  They  are  white  in  color,  and  therefore  reflect  exceeding^  well. 
Besides,  they  are  exceedingly  light,  durable — for  they  can  be  thrown  on  the 
floor  without  damaging  them  in  the  least — and  are  not  affected  by  acids. 
Only  absolute  alcohol  and  camphor  injure  them.  They  are  not  expensive, 
costing  about  one  dollar  a  speculum.  In  short,  they  are,  in  my  opinion, 
the  best  cylindrical  speculum  in  existence.  They  can  be  had  of  F.  G, 
Otto  &  Sons,  New  York. 

Tubular  vaginal  specula  should  vary  in  diameter  from  ^"  to  2",  and  in 
length  from  4"  to  6",  never  longer  than  the  latter,     A  short  speculum  will 


Fig.  39.— Set  of  Hard-rubber  or  Metal  Cylindrical  Specula. 

keep  the  cervix  within  easy  reach,  for  touch  and  vision,  while  a  long  tube 
pushes  it  away  and  renders  it  less  accessible.  This  is  not,  however,  of 
importance  for  indagation,  as  some  authors  state  ;  for  what  the  touch  can 
tell  us  about  the  cervix  should  have  already  been  ascertained  before  the 
speculum  is  introduced  ;  but,  in  order  to  enable  us  to  see  the  cervix  and 
reach  it  readily  with  forceps  and  other  instruments.  Thomas  has  devised 
what  he  calls  a  "  telescopic  "  speculum,  but  I  am  not  aware  that  it  has 
ever  become  popular,  probably  because  a  long  speculum  can  be  shortened 
by  not  introducing  it  to  its  whole  length,  and  specula  are  no  longer  made 
too  long  ;  and  finally,  because  tubular  specula  are  now  rarely  used  for  any- 
thing more  than  inspection,  and  the  inti'oduction  of  some  medicinal  agent 
into  the  vagina,  but  never  for  any  greater  operations  on  the  cervix  than 
the  passage  of  the  sound,  or  division  of  the  external  os,  or  scarification  of 
the  cervix. 

Cylindrical  specula  are  now  always  made  with  a  trumpet-shaped  expan- 
sion at  the  outer  end  for  the  purpose  of  admitting  more  light,  and  are 
generally  bevelled  off  at  the  inner  extremity  partly  to  facilitate  introduc- 
tion and  partly  on  account  of  the  greater  depth  of  the  posterior  pouch  of 


EXAMIN"ATION"    WITH   THE    SPECULUM.  75 

the  vagina  into  -which  the  bevelled  point  fits.     Some  specula  are  made 
square  cut  at  the  inner  end,  but  the  bevelled  ones  are  j^referable. 

The  tubular  speculum  will  always  retain  its  popularity  with  the  general 
practitioner,  who  but  rarely  has  to  make  a  specular  examination  and 
merely  desires  to  catch  a  glimpse  of  the  cervix  uteri,  often  with  no  par- 
ticular object  in  view,  and  hence  with  no  result ;  besides,  not  requiring 
assistance  and  being  simple  in  construction  and  cheap,  it  naturally  answers 
several  requirements.  As  already  stated,  for  inspection  of  the  vaginal 
walls  and  cervix,  for  application  of  fluid  or  pulverized  medicinal  sub- 
stances to  these  parts,  for  the  introduction  of  medicated  tampons,  for  the 
application  of  leeches  (where,  indeed,  it  is  almost  indispensable)  for  scar- 
ification of  the  cervix,  and  even  for  division  of  the  external  os  ;  for  the 
introduction  of  the  sound  or  probe,  and  frequently  of  cotton-wrapped  and 
medicated  applicators,  the  cylindrical  speculum  (especially  the  larger  sizes) 
answers  every  purpose,  and  is,  therefore,  by  no  means  to  be  discarded, 
even  by  the  specialist.  Thus,  in  very  capacious  vaginae  with  flabby  walls, 
I  often  find  a  large,  short  tubular  speculum  much  more  convenient  for 
examination  and  treatment  of  the  cervix  than  either  a  bivalve  or  Sims, 
through  which  latter  manipulations  are  interfered  with  by  the  constantly 
prolapsing  vaginal  walls.  But  with  these  applications  its  field  of  utility 
ends.  The  operations  for  laceration  of  the  cervix,  or  for  vesico-vaginal 
fistula,  or  of  division  of  the  os  internum,  would  be  impossibilities,  if  we  had 
to  attempt  them  through  a  tubular  speculum.  Even  the  introduction  of 
the  sound  or  applicator  may  be  difficult  or  impossible  through  the  tube,  if 
the  uterine  canal  is  tortuous,  as  in  anteflexion,  or  narrow. 

While,  therefore,  for  all  the  really  important  technical  and  operative 
TOocedures  in  modern  gynecological  practice,  the  tubular  speculum  is  in- 
adequate or  useless,  and  has  long  since,  in  the  hands  of  specialists,  given 
way  to  the  incomparable  duck-bill  of  Sims,  still  there  are  certain  conditions 
in  which  it  is  a  convenient  and  useful  instrument ;  and  writing  as  I  am,  not 
for  the  specialist,  but  for  the  beginner  and  general  practitioner,  I  feel  that 
they  will  thank  me  for  instructing  them  in  its  use,  even  though  I  but 
rarely  employ  it  myself.  While  freely  accepting  the  new,  it  is  not  well  to 
entirely  cast  away  the  old,  when  our  own  or  our  patient's  comfort  seems 
increased  by  our  conservatism. 

The  size  of  speculum  most  commonly  called  for  is  that  con-esponding 
to  No.  3  of  my  hard-rubber  set,  one  and  a  quarter  inch  outside  diameter. 
The  practitioner  should,  however,  possess  the  set  of  these,  or  equivalent 
sizes  of  milk-glass  specula,  a  few  of  which  latter  are  always  useful  in  dark 
weather  or,  in  the  smallest  size,  for  unmarried  women. 

Introduction. — The  ordinary  position  for  introducing  a  cylindrical 
speculum  is  the  dorsal,  as  already  described.  The  patient  is  covered  with 
a  sheet,  which  is  so  wound  about  her  legs  as  to  hide  them  from  \'iew  and 
expose  only  the  vulva.  The  physician  stands  between  the  thighs  of  the 
patient  slightly  toward  her  right  side,  seizes  the  trumpet-shaped  expansion 
of  the  otherwise  well-anointed  speculum  with  the  full  right  hand,  and 
while  the  thumb  and  index-finger  of  the  left  hand  separate  the  labia  and 


76  GYjSTECOLOGICAL    EXAMIISTATION. 

expose  the  vaginal  orifice,  passes  the  bevelled  end  with  the  point  against 
the  posterior  commissure  into  the  vaginal  orifice.  As  soon  as  the  bevelled 
point  is  fairly  engaged  under  the  pubic  arch,  steady  backward  pressure  is 
made  on  the  perineum  with  the  speculum  until  the  short  portion  of  the 
bevelled  extremity  is  below  the  bulb  of  the  lu-ethra  and  therefore  below 
the  pubic  arch  also,  when  the  point  is  gently  pushed  inward  and  what- 
ever resistance  may  have  been  experienced  ceases.  Either  by  gentle 
rotary  movements  or  steady-  upwai'd  pressure  (it  is  immaterial  which), 
the  sjDeculum  is  passed  inward,  the  phj^sician  noting  the  color  and  ap- 
pearance of  the  mucous  membrane  of  the  vagina  and  the  character  of  the 
secretion,  if  any  exist,  and  the  cervix  sought  for,  the  position  of  which 
organ,  be  it  remembered,  should  always  have  been  ascertained  by  pre- 
vious indagation.  If  this  precaution  has  been  neglected  the  cervix  may 
often  elude  the  speculum  for  some  time,  especially  if  a  displacement  of 
the  uterus  is  present.  The  cervix  is  recognized  chiefly  by  its  central 
opening,  the  os,  but  also  by  pecuharities  of  superficial  appearance  fre- 
quently met  with  in  that  part  (erosion,  enlarged  follicles),  and  by  its 
resistance  to  the  further  advance  of  the  speculum.  Some  experience  is 
required  always  to  recogTiize  the  cervix,  particularly  in  the  nullipara 
whose  cervix  is  unfissured  and  generally  of  exactly  the  same  color  as 
the  vaginal  mucosa ;  folds  of  vagina  often  interpose  in  the  lumen  of  the 
tube  and  by  their  transverse  rugse  simulate  the  external  os,  but  such 
folds  can  be  pushed  aside  by  sound  or  forceps  and  their  true  nature  thus 
easily  detected.  Ordinarily  the  speculum  pushed  straight  backward  and 
upward  in  the  axis  of  the  vaginal  canal  will  meet  the  cervix  about  three 
inches  above  the  orifice  ;  but  if  the  body  of  the  uterus  be  displaced  back- 
ward, forward,  or  laterally,  the  point  of  the  speculum  must  be  directed 
in  the  opposite  direction  to  find  the  cervix.  Occasionally  I  have  found 
it  so  difficult  to  engage  the  cenax  in  the  lumen  of  the  tube,  that  I  have  in- 
troduced the  sound  into  the  uterus,  and  passed  the  sijeculum  over  the 
sound,  and  frequently  it  is  found  necessary  to  draw  the  cervix  into  the 
speculum  with  the  tenaculum. 

Besides  this  difficulty  of  finding  the  cei*vix,  I  have  noticed  beginners 
to  have  trouble  in  inserting  the  point  of  the  sj)eculum  well  into  the  vagi- 
nal orifice,  or  rather,  they  would  attempt  to  push  the  jDoint  beyond  the 
line  of  the  symphysis  without  first  depressing  the  perineum,  as  above  de- 
scribed. The  result  was  the  causation  of  great  pain  to  the  patient,  whose 
lu'ethral  bulb  was  thus  caught  by  the  edge  of  the  sjDeculum  and  forcibly 
pushed  inward,  and  the  inability  of  completing  the  introduction.  All  this 
is  avoided  by  carefully  following  out  the  rule  above  described,  always  to 
depress  the  perineum  thoroughly  with  the  speculum  (this  gives  httle  or  no 
pain)  before  attempting  to  pass  it  under  the  pubic  arch.  This  obstacle 
overcome,  the  remainder  of  the  manipulation  is  painless,  unless  the  instru- 
ment be  too  large,  the  parts  inflamed,  or  the  point  pushed  too  forcibly 
into  the  vaginal  jjouch.  Occasionally,  the  perineum  is  so  rigid  and  the 
contraction  of  the  levator  ani  muscles  so  excessive,  as  to  render  the  intro- 
duction of  the  speculum  difficult  or  impossible  ;  such  rigidity  or  contrac- 


EXAMINATION    WITH   THE    SPECULUM.  77 

tion  may  be  normal  to  the  patient,  but  it  is  generally  due  to  reflex  action 
produced  by  fear,  and  the  first  touch  of  the  speculum. 

I  have  a  patient,  whose  capacity  readily  admits  the  largest  size  (2"  diam- 
eter), but  whose  perineal  and  levator  ani  muscles  contract  so  forcibly  at 
every  examination,  that  even  the  finger  meets  with  opposition,  and  every 
specular  examination  (with  whatever  form  of  speculum  it  is  made)  causes 
decided  expressions  of  pain  on  the  part  of  the  patient.  The  presence  of  a 
urethral  caruncle,  which  has  been  inadvertently  touched  by  the  operator, 
may  also  give  rise  to  the  same  reflex  spasm.  Pendulous  nymphse  occa- 
sionally form  a  momentary  obstacle  to  the  insertion  of  the  speculum. 

The  cervix  once  engaged  in  the  speculum,  one  of  the  first  points  to 
notice  is  the  presence  and  character  of  discharge  from  the  os,  whether  it 
is  thin,  glairy,  purulent,  discolored.  Attention  should  then  be  paid  to  the 
size  and  color  of  the  cervix  (normal,  pale  pink,  or  purple  or  mottled),  the 
size  of  the  os  (normal,  round,  transverse,  or  patulous),  the  nature  of  its 
edges  (smooth  or  fissured).  A  purple  color  of  the  cervix  may  mean  preg- 
nancy, or  may  only  indicate  the  venous  hyperemia  of  subinvolution  ;  or  it 
may,  indeed,  be  caused  by  the  pressure  of  a  too  tightly  fitting  speculum. 
A  mottled  appearance,  small,  yellow,  semi-opaque  dots  scattered  over  the 
pink  surface,  show  occluded  follicles,  retention  cysts,  so-called  ovula  Xa- 
bothi.  The  eversion  of  the  bright  red  and  rugous  cervical  mucosa  by  the 
circular  x^ressure  of  the  speculum  should  not  be  mistaken  for  an  erosion 
or  "  ulceration "  of  the  cervix  ;  the  diagnosis  is  easily  made  by  slightly, 
withdrawing  the  speculum  when  the  everted  ceiwical  mucosa  will  become 
reinverted,  and  the  red  surface  disappear,  while  an  erosion  remains  un- 
changed. It  is  not  always  easy,  however,  to  differentiate  between  these 
two  conditions,  when  there  is  a  deep  laceration  of  the  cervix,  the  lips  of 
which  are  so  much  everted  and  hyperplastic  (like  a  split  celery-top— 
Goodell),  that  they  cannot  be  included  in  the  speculum  ;  all  we  see  then 
is  a  large,  raw-looking  surface  entirely  filling  the  opening  of  the  speculum, 
and  looking  exactly  like  an  indolent  ulcer.  This  is  the  condition  so  long 
considered  to  be  and  called  "  ulceration  of  the  womb,"  when  the  cylindiical 
speculum  was  the  only  one  in  use,  and  for  that  matter,  still  so  termed  and 
treated  accordingly  by  many  practitioners  of  the  present  day,  to  whom  the 
Sims  speculum  is  an  unknown  quantity.  The  diagnosis  in  such  cases 
should  be  made  by  the  finger,  and  the  appearance  of  the  everted  sm-face 
merely  verified  by  the  speculum. 

In  hyperplasia  and  epithelioma  (cauliflower  growth)  of  the  cen-ix,  the 
latter  may  also  be  so  much  enlarged  as  to  exceed  in  diameter  the  lumen 
of  even  the  largest  speculum. 

In  cases  where  the  cervix  is  very  much  displaced,  especially  if  it  or  the 
fundus  uteri  is  fixed  by  adhesions,  it  may  be  impossible  to  get  it  into  the 
speculum. 

I  have  described  the  dorsal  position  as  the  one  in  which  a  specular  ex- 
amination should  be  made,  and  it  is  indeed  that  universaUy  employed  for 
the  purpose.  Only  in  some  English  text-books  is  the  lateral  position  rec- 
ommended.    Since  I  have  adopted  the  Sims  speculum  for  every  examma- 


78  GYNECOLOGICAL    EXAMIlS'ATIOlSr. 

tion,  I  have  also  been  in  the  habit  of  introducing  the  tubular  and  bivalve 
specula  in  the  lateral  position,  and  have  found  this  practice  in  nowise 
inferior,  and  in  some  respects  greatly  superior,  to  the  dorsal  position.  The 
chief  advantage  of  the  lateral  position  is  that  the  patient  is  much  less  ex- 
posed, as  the  sheet  can  be  so  arranged  as  to  cover  her  completely,  leaving 
only  the  vulva  in  sight,  without  becoming  disarranged  and  obstructing  the 
view,  as  so  often  happens  in  the  dorsal  position  when  it  is  not  retained  by 
an  assistant  or  nurse.  At  all  events,  the  patient's  face  is  so  placed  that 
she  cannot  see  how  much  she  is  exposed,  or  what  the  physician  is  doing. 
The  comfort  of  feeling  that  the  patient  is  not  watching  one's  every  ex- 
pression and  movement  has  but  to  be  experienced  in  order  to  be  appreci- 
ated. Another  advantage  of  putting  the  patient  on  the  side  for  every 
specular  examination  is,  that  the  position  will  not  require  to  be  altered 
again  for  the  use  of  the  Sims  speculum,  or  the  digital  eversion,  or  the  ex- 
amination of  the  rectum. 

The  details  of  the  introduction  of  the  speculum  are  the  same  as  those 
described  ;  the  left  hand  merely  lifts  the  right  labium  majus,  whereby  the 
labia  are  separated  and  the  vulvar  cleft  made  to  gap  ;  the  point  of  the 
si^eculum  is  inserted  and  the  perineum  depressed  in  precisely  the  same 
manner  as  in  the  dorsal  position,  the  physician  standing  slightly  behind 
the  patient.  The  speculum  should  be  passed  rather  more  backward  in  this 
position,  as  the  normal  antecurvature  of  the  uterus  is  slightly  increased  to 
anteversion,  and  the  cervix,  therefore,  stands  rather  nearer  the  sacral  ex- 
cavation, than  in  the  dorsal  decubitus.  It  should  be  remembered  that  the 
longer  end  of  the  speculum  is  always  to  go  behind  the  cervix,  which  can 
be  regulated  by  introducing  the  speculum  as  above  directed,  and  not  ro- 
tating it. 

2.  The  hi-  and  trivalve  specula. — As  the  chief  desiderata  of  tubular  spec- 
ula are  durability  and  reflection  of  light,  so  are  those  expanding  specula 
the  best  which  are  the  least  complicated  and  permit  the  widest  separation 
at  their  vulvar  end.  All  bi-,  tri-  and  quadrivalve  specula  are  so  con- 
structed as  to  have  the  fixed  point  of  their  branches  at  the  vulvar  portion 
of  the  instrument,  where  the  screws  or  levers  are  situated  which  separate 
the  blades.  Thus  the  distal  ends  are  more  widely  separated,  while  the 
vaginal  orifice  is  comparatively  but  httle  distended. 

These  specula  are  made  of  metal,  at  the  present  time  all  nickel-plated. 
While  more  expensive  than  the  round  specula,  they  are  more  durable  and 
less  Hkely  to  get  out  of  order,  merely  requiring  occasional  replating.  For- 
merly, many  plurivalvular  specula  were  made  with  four,  five,  and  even  six 
blades,  but  at  the  present  day  it  is  conceded  that  two  and,  chiefly,  three- 
bladed  instruments  answer  every  purpose  attainable  by  a  speculum  of  this 
construction.  The  blades  are  in  the  vast  majority  of  instruments  expanded 
in  the  autero-posterior  direction,  and  many  specula  have  a  slit  at  the 
vulvar  end  of  the  upper  blade  to  prevent  pressure  on  the  urethra.  The 
inner  ends  are  well  levelled  and  rounded  off,  and  the  branches  approximate 
so  closely  as  to  offer  no  obstacle  to  introduction.  A  few  specula,  bivalve 
and  trivalve,  are  so  constructed  as  to  expand  laterally.     As  a  rule,  the 


EXAMINATION    WITH    THE    SPECULUM. 


79 


trivalve  specula  consist  of  one  posterior  concave  blade,  and  two  slightly 
curved  anterior  blades,  which  separate  in  the  antero-posterior  diameter,  the 
anterior  blades  being  so  curved  as  also  to  distend  the  vaginal  pouch  later- 
ally to  a  slight  extent.  The  posterior  blade  is  generally  longer  (4^")  than 
the  anterior  (4"),  corresponding  to  the  greater  length  of  the  posterior 
va^-inal  wall.  For  the  same  reason  as  mentioned  in  speaking  of  the  cylin- 
drical, the  valve  s^Decula  should  not  be  too  long,  certainly  not  longer  than 
5".  A  long  speculum  pushes  the  cervix  up,  Avhile  one  just  long  enough  to 
reach  behind  the  cervix,  when  expanded,  naturally  shortens  the  vaginal 
canal  and  brings  the  cervix  down  into  its  lumen. 

The  advantage  claimed  for  the  plurivalve  specula  is  the  greater  exposure 
of  the  vaginal  walls  ;  but  this  advantage  is  more  or  less  counterbalanced 
by  the  diminished  reflection  of  light,  and  by  the  tendency  of  the  vaginal 
walls,  when  lax,  to  crowd  between  the  blades  of  the  speculum.  Trivalve 
specula  certainly  possess  greater  degrees  of  expansion  than  bivalve,  and 
are  therefore  usually  more  ser-  ,. — .. 


^\ 


Fig.  33. — Brewer's  Speculum. 


viceable  if  any  manipulation  is 
intended  on  the  cervix  or  en- 
dometrium ;  and  if  it  is  advis- 
able to  inspect  the  posterior 
vaginal  wall  (say,  for  a  recto- 
vaginal fistula)  a  quadrivalve 
may  even  be  indispensable. 
For  mere  inspection  of  the  va- 
ginal pouch  and  cervix  a  bi- 
valve with  fairly  large  vulvar 
ring  will  generally  answer. 

Of  the  older  bivalve  specula, 
the  Cusco  was  the  most  popu- 
lai',  and  is  still  mentioned  in 
every  text-book.  In  its  orig- 
inal, unimproved  form  it  no  longer  deserves  approval,  for  its  length  is  5" 
and  while  its  internal  expansion  is  sufiicient  (3")  its  vulvar  orifice  is  so 
small  (1^")  as  to  admit  but  little  light  and  permit  of  scarcely  any  operative 
procedure  on  the  cervix.  In  its  modified  form,  it  is  shorter,  has  a  wider 
valvular  expansion,  and  is  a  tolerably  serviceable  instrument.  Of  the  val- 
vular expanding  specula  now  in  use,  I  shall  mention  a  number  in  their 
order  of  practical  utility  (so  far  as  my  experience  goes),  beginning  with 
the  best  and  referring  for  the  description  of  the  indi^ddual  instruments 
to  the  catalogues  of  the  instrument- makers.  Bivalve  :  Brewer's,  Hunter's, 
Goodell's  (lateral  expansion),  Fallen's,  Leonard's,  Cusco's  improved.  Tri- 
valve :  Nott's,  Ball's,  Nelson's,  Meadows'.  Quadrivalve  :  Meadows'.  I  pre- 
sume my  preference  and  discrimination  in  the  oixler  of  these  specula  will 
not  meet  with  universal  approval ;  usually,  every  inventor  considers  the 
product  of  his  brain  the  best.  But,  having  put  the  beginner  in  search  of  a 
speculum  on  the  track,  I  must  leave  him  to  create  his  own  preference. 
Every  one  of  the  specula  mentioned  is  a  serviceable  instrument,  as  doubt- 


80 


GYNECOLOGICAL    EXAMINATION. 


less  are  many  others  with  which  I  have  not  become  acquainted.  I  myself 
possess  a  Brewer  (which,  besides,  has  the  occasionally  useful  quality  of  be- 
ing transformable  into  a  Sims  by  reversing  the  blades)  and  a  modified  Nott 
(in  which  the  vulvar  ring  can  be  greatly  enlarged  by  a  sUding  apparatus, 
to  be  described  hereafter  in  connection  with  the  combined  specula),  and 
cannot  imagine  the  necessity  for  a  greater  variety.     In  case  of  need,  the 


Fig.  34. — Goodell's  Speculum. 

posterior  vaginal  wall  can  be  exposed  by  simply  turning  the  two  anterior 
blades  backward. 

Bi-,  tri-,  and  quadrivalve  specula  are  useful  for  exposing  the  cervix  and 
vaginal  vault  (the  latter  according  to  the  degree  of  their  internal  expansion), 
and  certain  parts  of  the  vaginal  walls.  They  permit  the  application  of 
agents  to  the  cervix,  and  the  introduction  of  tampons  into  the  vagina 


e.T/EMAm-co 
Fig.  35. — Nott's  Speculum. 

quite  as  well  as  the  tubular  specula,  and  for  the  introduction  of  substances 
(sound,  applicator,  bougies),  into  the  cervical  and  uterine  canal  they  are 
decidedly  superior  to  the  tubular,  as  they  give  more  room  and  approxi- 
mate the  cervix  to  the  vulva.  But  for  the  application  of  fluid  or  pulverized 
substances  to  the  vaginal  walls,  and  the  leeching  of  the  cervix,  the  valve 
instruments  are  inferior. 

Introduction. — The  valvular  specula,  like  the  tubulai',  may  be  intro- 
duced either  in  the  dorsal  or  lateral  position.  The  vulvar  portion  of  the 
instrument  is  seized  in  the  full  right  hand,  and  the  rounded  point  of  the 
closed  blades  pressed  in  their  transverse  diameter  into  the  corresponding 


EXAMI^fATION    WITH    THE    SPECULUM.  81 

antero-posterior  vulval-  cleft  and  under  the  pubic  arcli  in  precisely  the 
same  manner  as  described  under  the  cylindrical  sj^ecula.  As  soon  as  the 
tip  has  passed  into  the  vagina,  the  siDeculum  is  turned  with  the  screw  and 
handle  downward  (if  the  patient  be  in  the  dorsal  position),  or  backward 
(if  she  be  on  the  side),  and  the  speculum  is  pushed  gently  into  the  vagina 
until  its  hilt  almost  presses  against  the  perineum.  The  screw  is  then 
turned  down  until  the  ceiwix  appears  in  the  lumen  of  the  speculum  or  the 
branches  are  opened  to  their  utmost,  or  the  handles  may  be  rapidly  ap- 
proximated and  the  screw  not  turned  down  tmtil  the  cervix  is  caught.  If 
the  cervix  does  not  at  once  appear  in  the  lumen,  the  speculum  should  be 
slightly  withdrawn  and  reintroduced,  or  its  point  be  directed  toward  the 
spot  where  previous  indagation  has  sho-\vn  the  cervix  to  be  situated,  and 
the  branches  then  again  separated.  When  thoroughly  expanded,  particu- 
larly in  rather  tense,  contractile  vaginal  walls,  a  plurivalvular  speculum  is 
retained  in  place  without  assistance  of  the  hand,  a  manifest  advantage 
when  it  becomes  necessary  to  draw  the  cervix  into  its  lumen  or  steady  it 
with  a  tenaculum  before  obtaining  a  good  view  of  it  or  succeeding  in  in- 
troducing a  sound,  etc.,  into  the  uterine  cavity.  This  retention  is  aided 
by  elevating  the  pelvis  on  a  cushion.  There  is  usually  no  particular  diffi- 
culty in  exposing  the  cervix  with  a  valvular  speculum,  unless  the  vaginal 
walls  are  so  flabby  that  they  drop  before  the  cervix  and  hide  it  from  view. 
If  the  instrument  is  introduced  too  far  before  being  expanded  its  point 
may  go  behind  or  before  the  cervix,  and  the  latter  be  pushed  forward  or 
backwax'd  when  the  blades  are  exjoanded,  of  course  entirely  removing  it 
from  view. 

The  introduction  and  expansion  of  the  sj)eculum,  and  exj)osure  of  the 
cervix,  are  quite  as  easy  in  the  lateral  as  in  the  dorsal  position.  The  plain 
lateral  is  preferable  to  the  latero-abdominal  for  this  purpose,  since  the 
mouth  of  the  speculum  does  not  dip  so  much,  and  any  fluid  which  may 
have  been  introduced  into  the  vagina  is  less  likely  to  flow  out  accidentally 
and  burn  the  vulva  and  external  genitals. 

Neither  the  tubular  nor  valvular  specula  are  properly  self-retaining. 
If  the  patient  remains  perfectly  quiet  and  does  not  bring  her  abdominal 
muscles  and  intra-abdominal  pressure  to  bear  on  the  intra-jDchic  organs, 
the  speculum  may  be  retained  "without  the  guarding  hand  of  the  jihysi- 
cian.  As  a  rule  it  is  safer,  if  the  physician  has  other  use  for  both  his 
hands,  to  ask  the  patient  to  place  her  fingers  on  the  upper  margin  of  the 
speculum  and  keep  it  in  place.  It  is  very  awkward  to  have  a  sj^eculum 
forced  out  by  the,  perhajDS  involuntary,  movement  or  straining  of  the  pa- 
tient, and  her  clothes  soiled  by  the  agent  which  had  been  introduced  into 
the  tube. 

In  withdi-awing  the  speculum  care  should  be  taken  to  do  so  gently  and 
not  to  clap  the  blades  forcibly  togethei',  as  folds  of  vaginal  wall  or  \-ulvar 
tissue  are  readily  caught  between  them  and  bruised. 

With  the  bivalve  speculum  only  the  vault  and  lateral  walls  of  the  va- 
gina are  exposed  ;  with  the  trivalve  also  the  anterior  wall  ;  with  the  quad- 
rivalve,  a  portion  of  the  posterior  wall  also  can  be  seen. 
6 


82  GYNECOLOGICAL    EXAMIKATIOK. 

The  Univalve  or  Duck  bill  Speculum. — Wliile  the  cylindrical  and  pluri- 
valvular  specula  all  act  by  separating  tlie  normally  apposite  walls  of  the 
vagina  by  mechanical  force,  the  univalvular  speculum  secures  the  same 
result  in  an  entirely  different  manner.  It  can  attain  this  object  only  in  a 
position  of  the  patient  in  which  intra-abdominal  pressure  is  almost  or  en- 
tirely suspended  ;  the  function  of  the  speculum  is  then,  to  a  certain  ex- 
tent, merely  to  admit  air  into  the  vagina,  when  that  canal  becomes  dis- 
tended, and  its  walls  and  the  cervix  would  be  distinctly  visible,  did  not  the 
collapse  of  the  soft  vulvar  folds,  although  admitting  the  air  by  a  cleft,  in 
a  great  measure  obstruct  the  view.  If  that  were  not  the  case,  the  mere 
introduction  of  the  finger  into  the  vagina  would  do  quite  as  well  as  the 
duck-bill ;  indeed,  in  some  gaping  vulvae,  as  they  are  found  in  multiparse, 
or  women  with  lacerated  perineum,  the  mere  assumption  of  the  semiprone 
or  knee-chest  position  will  expand  the  vagina  and  expose  the  cervix. 
Thus,  in  the  absence  of  a  speculum,  the  two  fingers  may  be  used  in  the 
semiprone  position  to  retract  the  perineum  and  expand  the  vagina,  often 
exposing  the  cervix,  and  proving  useful  for  the  introduction  or  removal  of 
tampons. 

The  mere  admittance  of  air,  therefore,  into  the  vagina  does  not  suffice 
to  give  a  clear  view  of  its  interior  ;  the  firm  retraction  of  the  perineum  by 
the  speculum,  and  the  separation  of  the  labia  are  necessary  to  admit  light 
into  the  vagina.  This  purpose  was  accomplished  by  Sims,  when,  twenty- 
five  years  ago,  he  accidentally  discovered  the  princi- 
ple and  from  it  devised  his  famous  speculum  ;  this 
speculum  which,  in  its  elegance,  simplicity,  and 
efficiency,  has  in  all  these  years  been  found  incajDable 
of  improvement.  It  is  not  necessary  for  me  here  to 
enter  upon  the  circumstances  which  led  to  this  dis- 
covery— a  discovery  which  has  revolutionized  the 
whole  practice  of  gynecology,  and  has  made  a  science 
of  what  formerly  was  merely  a  profession.  In  my 
opinion,  the  Sims  speculum  is  the  only  absolutely 
perfect  speculum,  and  it  seems  to  me  that  it  would 
be  preferable  to  give  up  the  specialty  rather  than 
FiG.36.-Sims'  speculum.  Practise  without  it.  Even  now,  aided  as  the  prac- 
titioner is  by  all  the  improved  methods  of  examina- 
tion and  diagnosis  described  in  the  modern  text-books,  he  who  neglects  to 
examine  a  patient  suffering  from  uterine  disease  with  the  Sims  speculum 
labors  under  a  disadvantage,  and  deprives  his  patient  of  one  of  the  greatest 
discoveries  in  modern  medical  science.  Only  through  the  Sims  speculum 
can  the  cervix  be  seen  undisturbed  and  movable,  with  non-everted  os  and 
unimpeded  circulation,  and  can  the  uterus  be  examined  in  its  normal  posi- 
tion unfettered  by  the  enclosing  and  fixing  branches  of  a  speculum.  The 
criticism  which  I  have  heard  made  on  Sims'  speculum  by  gynecologists 
of  the  old  school,  that  its  backward  traction  displaces  the  uterus  and 
everts  the  external  os,  and  that  the  result  of  every  such  examination  is  an 
abnormal  one,  is  simply  absurd,  and  can  be  refuted  at  any  examination. 


EXAMINATION    WITH   THE    SPECULUM. 


83 


It  is  unfortunate  that  the  proper  use  of  the  Sims  speculum  absolutely 
requires  the  assistance  of  a  nurse  or  assistant  to  hold  the  instrument  and 
elevate  the  superior  buttock,  for  the  general  practitioner  and  young  spe- 
ciahst  is  thereby  ordinarily  prevented  from  using  it  habitually  in  private 
practice.  But  this  objection,  commonly  advanced  against  it,  is  no  argu- . 
ment  whatever  against  the  value  of  the  instrument.  I  found  it,  in  former 
years,  quite  possible  to  do  without  a  nurse  and  stiU  use  my  Sims  effi- 
ciently in  ordinary  examinations  and  applications,  by  the  aid  of  the  lateral 
and  longitudinal  tip-table  described  on  page  30.  Whenever  both  hands 
were  required,  I,  of  course,  employed  a  nurse,  as  I  now  always  do,  for 
such  a  person  certainly  is  a  great  convenience  ;  and,  besides,  her  presence 
protects  the  physician  against  malicious  accusations  of  attempted  outrage, 
etc.,  which  designing  females  occasionally  make  for  purpose  of  blackmail. 

As  for  operations  on  the  cervix  and  vagina,  suffice  it  to  say  that  the 
duckbill  of  Sims  has  alone  rendered  them  possible  and  successful.     The 


Fig.  37.— Dawson's  Modification  of  Sims''  Speculum  (double-hinge),  for  Convenience  of  Transportation. 

similar  instrument  of  Simon,  it  is  true,  affords  easy  view  of  access  to  the 
vagina  and  cervix,  but  it  is  used  in  the  dorso-gluteal  position,  the  anterior 
and  lateral  walls  being  separated  by  flat  hooks  held  by  assistants  (three), 
and  therefore  acts  merely  on  the  principle  of  mechanical  expansion. 

Practically  there  is  only  one  Sims  speculum  of  various  sizes  ;  but  sev- 
eral minor  modifications  have  been  given  it,  such  as  an  increased  curve  of 


Fig,  38.— Mund6's  Modified  Sims  to  Support  the  TJpper  Buttock  (P.  F.  M.). 


the  handle,  or  diminished  angle  of  blades,  whereby  traction  is  facilitated ; 
or  broader  and  shorter  blades,  so  as  to  distend  the  posterior  wall  more  and 
bring  the  cervix  closer  to  the  vulva  for  operations  ;  or  the  addition  of  a 
hinge  at  the  angle  of  each  blade  and  the  handle,  to  facilitate  the  carrj-ing 
of  the  instrument  (Dawson)  ;  or  the  separation  of  the  blade  into  two  equal 
halves  by  means  of  a  screw  or  bar,  so  as  to  expose  the  posterior  wall  of 
the  vagina  (Dawson)  ;  or  the  expansion  of  the  upper  edge  of  the  blade  into 
a  flange,  so  as  to  support  the  uj^per  buttock  and  prevent  it  from  obstnicting 
the  view.     The  latter  modification,  which  I  truly  think  may  be  termed  an 


84 


GYNECOLOGICAL    EXAMINATION. 


improvement,  has  of  late  been  used  almost  exclusively  by  me  when  exam- 
ining without  a  nurse,  and  has  proved  itself  so  efficient  as  to  be,  in  my 
opinion,  indispensable.  The  broad  flange  is  moulded  on  to  the  ordinary 
Sims,  and  can  be  bent  at  wiU  to  any  desired  cui-ve. 

Of  the  ordinary  shaped  Sims  (see  Fig.  36),  there  are  generally  four 
sizes,  two  on  each  handle  ;  besides  a  smaller  speculum,  also  two  sizes,  for 
a  virgin  or  very  narrow  vagina.  The  instruments  are  silver-  or  nickel- 
plated,  and  very  durable,  but  require  frequent  replating. 

Indispensable  adjuvants  to  the  Sims  speculum  are  the  depressor  and 
tenaculum  ;  the  former  to  press  forward  the  anterior  vaginal  wall  and  bring 


L 


Fig.  39. 


gj-jj^^^^.r.- 


Fig.  40. 


Fig.  41. 


Figs.  39,  40,  41. — Diflferont  Shapes  of  Tenacnla. 

the  cervix  into  the  axis  of  the  canal,  and  the  latter  also  to  bring  forward 
and  steady  the  cervix.  The  depressors,  of  which  cuts  are  here  given,  are 
the  best.     The  tenacula  represented  in  Figs.  40  and  41  have  a  somewhat 


Fig.  42.— Solid  Shank  Tenaculum. 


=1 


curved  hook,  and  are  less  liable  to  slip  or  tear  out  than  that  seen  in  Fig. 
39,  the  hook  of  which  is  at  right  angles.  The  latter  is  useful  in  opera- 
tions in  catching  up  sutures ;  but  both  varieties  are  frequently  sold  indis^ 


Fig.  43. — Sims'  Double-end  DepresBor. 


criminately,  to  the  subsequent  great  annoyance  of  the  operator.  "Where 
traction  is  desired,  the  curved  tenaculum  is  the  best ;  where  the  object  is 
to  approximate  two  surfaces,  as  the  lips  of   a  torn  cervix,  or  the  edges  of 


Fig.  44. — Sims"  Depressor,  with  Handle. 

any  wound,  the  rectangular  hooks  are  preferable.  The  tenacula  made  of 
one  solid  piece  of  steel,  with  simply  a  thin  wood  covering  on  the  handle, 
are  far  preferable  to  those  made  of  malleable  ix'on  fastened  in  a  wooden 
handle,  which  are  Uable  to  bend  under  pressure.     (See  Fig.  42.) 


EXAMIlSrATION    WITH    THE    SPECULUM. 


Mode  of  Using  the  DucJc-bill  Speculum. — The  patient  occupies  the  latero- 
abdominal  or  semiprone  position,  usually  the  left  (already  described),  on 
a  flat  table  or  couch,  with  her  hips  close  to  the  left  edge,  and  her  head 
near  the  right  upper  corner  of  the  table.  She  is  covered  with  a  sheet,  only 
her  vulva  being  exposed,  and  her  clothes  are  well  drawn  back  away  from 
the  sacrum  in  order  not  to  interfere  with  the  handle  of  the  speculum  ;  a 


Fig.  45. — Position  of  Patient,  Physician,  and  Niirse  in  E.^amination  with  Sims'  Speculum  (P.  F.  M.). 

tightly  laced  corset  or  dress  should  be  loosened.  The  lower  buttock  is 
covered  by  a  napkin  tucked  in  between  the  thighs  and  under  the  buttock, 
in  order  to  prevent  soiling  the  clothes.  The  physician  sits  behind  the 
patient  on  a  chair  of  convenient  height,  with  the  instruments  to  be  used 
(speculum,  depressor,  tenaculum,  sound,  probe,  and  dressing-forceps  in  a 
basin  of  warm  water  on  a  chair  or  table  at  his  right  hand.  The  examining- 
table  should  be  so  placed  and  the  physician  so  sit  as  to  permit  the  best 
light  to  fall  on  the  vulva.     He  takes  the  siDcculum  from  the  basin,  covers 


86 


GYNECOLOGICAL    EXAMINATION. 


the  outside  of  tlie  blade  to  be  used  with  an  emollient  (soapsuds,  vaseline, 
or  simple  water  will  do),  places  the  index-finger  of  his  right  hand  flat 
into  the  concavity  of  the  blade  to  be  introduced  ;  seizing  the  shank  with 
the  other  fingers  and  thumb,  and  gently  lifting  the  superior  or  right 
labium  with  the  other  hand  (or  the  nurse  may  do  this),  introduces  the 
point  of  the  blade  and  finger  with  the  concavity  downward  into  the  vaginal 

orifice.  As  soon  as  the  finger  and  specu- 
lum are  fairly  in  the  vagina,  the  con- 
cavity of  the  instrument  is  turned  for- 
ward, and  the  point  backward  toward 
the  coccyx,  and  the  blade,  guided  by 
the  finger,  along  the  posterior  wall 
of  the  vagina,  until  its  progress  is  ar- 
rested by  the  junction  of  blade  and 
handle  touching  the  perineum,  that  is, 
when  the  blade  is  completely  within  the 
vagina.  The  left  hand  of  the  operator 
then  seizes  the  external  blade  firmly  and 
makes  steady  traction,  the  line  of  trac- 
tion not  being  directly  backward,  but 
slightly  upward,  so  as  to  raise  the  upper 
buttock  and  admit  more  light.      Having 

Fig  46.-Manner  of  Holding  and  Introducing    thuS  thoroughly  retracted    the   periuCUm 

Sims'  Speculum  according  to  Sims.  ^^^  admitted  air  and  Hght   into  the  va- 

gina, perhaps  having  already  exposed  the  cei-vix,  the  speculum  is  handed 
to  the  nurse,  who,  standing  at  the  patient's  sacrum,  seizes  the  speculum  in 
her  right  hand  with  the  thumb  in  the  concavity  and  the  four  fingers  grasp- 
ing the  blade,  and  makes  steady  traction  backward  and  upward,  while  the 
four  fingers  of  her  left  hand 
draw  the  right  buttock  and 
labium  gently  upward.  The 
direction  of  traction  is  a  mat- 
ter of  great  importance  ;  if 
the  traction  is  made  straight 
backward  the  light  will  not 
enter  the  vagina  freely,  even 
though  the  superior  buttock 
is  raised  by  the  nurse,  since 
the  axis  of  the  vagina  will  be 

downward  ;  as  soon  as  the  shght  upward  twist  is  given  to  the  speculum 
the  vaginal  orifice  points  upward,  and  the  depth  of  the  vagina  is  at  once 
illuminated.  Further,  it  is  important  that  traction  should  be  so  exercised 
that  the  point  of  the  inner  blade  is  neither  directed  too  far  back  nor  again 
drawn  away  from  the  posterior  vaginal  wall ;  if  too  far  backward,  the  cei-v'ix 
is  drawn  out  of  sight,  and  if  too  forward— that  is,  if  the  nurse  draws  too 
much  toward  the  head  of  the  patient— the  speculum  may  be  entu'ely  pulled 
out  of  the  vagina. 


Fig.  47.— Manner  of  Holding  and  Introducing  Sims'  Speculum, 
Modified  (P.  F.  M.)- 


EXAMINATIOlSr    WITH   THE    SPECULUM. 


87 


Fig.  48.— Manner  of  Holding  Sims' 
Speculnm  for  Introduction  without 
Guidance  of  Finger  of  Eight  Hand 
(P.  F.  M.). 


I  have  found  it  useful  in  rapidly  exposing  the  cervix,  particularly  if  it 
is  situated  far  back  in  the  sacral  excavation,  first  to  employ  the  straight 
backward  traction,  as  described,  until  the  vagina  expands,  and  then  tilt 
the  inner  point  of  the  speculum  slightly  for- 
ward ;  by  this  maneuvre  the  cei-vix  is,  as  it 
were,  lifted  out  of  the  hollow  of  the  sacrum 
and  fully  exposed. 

The  expert  can  dispense  with  the  guiding 
finger  in  introducing  the  sj)eculum,  and  seiz- 
ing the  external  blade  in  his  right  hand,  and 
lifting  the  right  labium  with  his  left,  may 
gently  slip  the  blade  into  the  vagina  and  be- 
hind the  cervix,  closely  hugging  the  posterior 
wall.  The  beginner  is  liable  to  pass  the 
blade  too  far  forward  in  front  of  the  cervix, 
which  then,  of  course,  when  traction  is  made, 
is  drawn  backward  out  of  sight,  greatly  to 
the  astonishment  of  the  examiner,  who  can- 
not imagine  why  he  cannot  find,  the  cervix. 

By  grasping  the  speculum  as  above  di- 
rected, resting  the  right  forearm  on  her  right 
hij),  and  drawing  steadily  backward  in  a  direction  corresponding  to  a  line 
running  from  the  patient's  left  pubic  bone  to  her  right  tuber  ischii  (see 
Fig.  5),  the  trained  nui'se  can  stand  erect  and  bear  this  position  for  a  length 
of  time  entirely  impossible  for  an  inexperienced  j^erson.     It  is  important 

both  for  the  convenience  of  the  operator  and. 
the  comfort  of  the  patient  that  traction  be  steady 
and  the  speculum  be  shifted  by  the  cramped  or 
tired  fingers  of  the  nurse  as  Httle  as  possible. 
Steady  traction,  while  at  first  somewhat  j^ainful 
(and  it  is  this  traction  on  the  perineum  which 
causes  the  real  and  only  pain  complained  of 
during  an  examination  with  Sims'  speculum),  is 
soon  borne  without  a  murmur,  while  frequent 
shifting  of  the  instrument  always  causes  fresh 
pain.  Pain  may  also  be  caused  by  allowing  the 
lower,  rather  sharp  edge  of  the  blade  to  rest 
heavily  against  the  lower  labium,  as  is  the  case  when  traction  is  not  made 
in  the  prescribed  direction. 

This  question  of  traction  and  holding  the  speculum  is  exceedingly  sim- 
ple to  the  expert,  but  full  of  difficulty  to  the  beginner.  A  niu-se  un- 
trained in  this  particular  is  a  source  of  annoyance  and  positive  disturbance 
to  the  operator.  It  is  obvious  that,  in  order  to  give  the  nui'se  the  proper 
directions,  the  physician  shovild  himself  know  how  to  use  the  speculum. 
For  this  reason  I  have  been  rather  prolix,  perhaps,  in  the  above  descrip- 
tion. The  necessity  for  such  minute  detail  has  frequently  been  illustrated 
to  me  in  my  private  classes,  when  gentlemen  (often  older  practitioners) 


Fig.  49. — Mannerof  Holding  Sims' 
Speculum  accdtding  to  Sims  and 
Emmet. 


88  GYNECOLOGICAL    EXAMINATION", 

could  not  succeed  in  exposing  the  cervix,  simply  because  they  made 
straight  backwai'd  traction,  and  drew  too  much  on  the  point  of  the  inner 
blade.  A  mere  upward  twist  of  the  blade  and  forward  tilting  of  its  point 
would  at  once  bring  the  cervix  forward  and  in  full  view. 

As  a  rule,  I  follow  the  plan  of  first  thoroughly  exposing  the  cervix  and 
vagina  myself  by  the  speculum  in  the  left  and  the  depressor  in  the  right 
hand,  the  nurse  merely  drawing  uj)  the  right  labium,  and  do  not  hand  the 
speculum  to  the  nurse  until  I  have  it  exactly  where  I  want  her  to  keep  it ; 
any  subsequent  shifting  is  to  be  done  by  myself. 

The  above  method  of  holding  the  speculum  is  the  one  I  have  always 
practised  and  taught,  and  in  my  experience  it  has  proved  perfectly  satis- 
factory ;  indeed,  I  myself  have  repeatedly,  in 
assisting  friends  at  operations  for  laceration  of 
the  cervix,  held  the  speculum  in  this  way  for 
nearly  an  hoiu-  without  becoming  tired.  But 
Dr.  Emmet  in  his  recent  work  describes  a  some- 
what different  method,  which  to  me  certainly 
does  not  appear  as  comfortable  as  the  one  I 
employ.  After  sj^eaking  of  "traction  on  the 
peiineum"  with  the  speculum,  he  says:  "By 
placing  the  buttocks  close  to  the  angle  of  the 
table,  the  assistant  is  enabled  to  stand  sufiiciently 
behind  the  j)atient  to  steady  the  instrument. 
a.d1nt?^a7SsiL' WfcS  This  is  not  done  by  tractioufbut  by  using  the 
modified  (P.  F.  11.).  width  of  the  hand  like  a  wedge  between  the  but- 

tock and  ujoper  edge  of  the  sj)eculum.  The  central  portion  or  isthmus  of  the 
instrument  hes  against  the  flat  of  the  hand,  and  the  upper  part  between  the 
thumb  and  index-finger,  so  that  the  fingers  are  free,  and  can  be  moved  with- 
out disturbing  the  position  of  the  speculum.  By  thus  using  the  hand  as  a 
wedge,  the  instrument  can  be  steadily  held  in  place  for  hours,  during  a  long 
operation,  without  cramping  the  fingers.  It  promotes  greatly  the  comfort 
of  the  patient  to  have  the  instrument  held  in  this  manner,  and  enables  her 
to  relax  her  muscles,  which  she  cannot  do  if  the  perineum  and  rectum  are 
irritated  by  the  frequent  jerking  which  occurs  when  traction  is  made  by 
the  fingers  alone,  without  a  resting-place  for  the  hand,  as  I  have  described." 
When  I  speak  of  traction,  I  mean,  of  course,  a  steady,  unir^terinipted 
retention  of  the  speculum  in  the  position  in  which  it  was  handed  to  the 
nurse  after  the  cervix  was  exposed,  not  a  forcible,  spasmodic  j)ulling  at 
the  speculum.  It  is  true,  the  operator  exerts  the  traction  on  the  perineum 
before  he  hands  the  instrument  to  the  nurse,  who  keeps  the  perineum  in 
that  condition  of  retraction,  but,  after  all,  what  is  it  but  "  traction  "  which 
keeps  the  perineum  back  ? 

Emmet  foUows  Sims  in  this  method  of  holding  the  speculum,  and, 
therefore,  it  may  ajjpear  presumptuous  to  modify  the  inventor's  own  direc- 
tions. But  I  have  found  my  plan  sei-ve  me  admirably,  and  if  the  arm  is 
rested  against  the  side  and  hip,  much  less  fatiguing  than  the  full  grasp 
recommended  by  Sims  and  Emmet. 


EXAMINATION    WITH    THE    SPECULUM. 


89 


This  matter  must  naturally  be  a  question  of  habit  and  pi'actice,  and, 
doubtless,  both  plans  answer  equally  well  in  the  hands  of  the  expert. 

The  nurse  having  taken  charge  of  the  speculum,  the  operator  takes 
the  depressor  in  his  right  hand,  and  with  it  presses  the  anterior  wall  of 
the  vagina  forward,  thereby  drawing  the  cervix  still  farther  into  the  va- 
ginal axis.  If  necessary,  even  then,  to  attract  or  fix  the  cervix,  its  ante- 
rior lip  is  seized  by  a  tenaculum,  which  is  hooked  into  the  cervical  mucous 


Fig.  51. 


■Incorrect   Position   of   Patient  for  Examination  with  Sims'  Speculum  (Halliday  Croom, 
Leblond).     Illustrating  necessity  for  cleiailed  description  of  the  position. 


membrane  from  within  outward,  and  by  which  the  os  may  be  opened,  and 
the  whole  uterus  drawn  down. 

If  the  physician  is  obhged  to  examine  his  patient  without  the  assist- 
ance of  a  nurse,  his  left  hand  is  used  to  separate  the  labia,  and  then  seizes 
the  speculum,  and  gives  it  the  utmost  upward  twist  possible,  while  the 
right  hand  sharply  presses  forward  the  anterior  vaginal  wall  with  the  de- 
pressor. By  bowing  the  head,  the  eye  may  generally  succeed  in  reaching 
the  cer\ix,  and  getting  a  fair  glimpse  of  it.  The  overhanging  of  the  supe- 
rior buttock,  however,  usually  interferes  with  vision  ;  and  to  obviate  this, 
the  flanged  speculum  shown  in  Fig.  38,  should  prove  useful.  If  the  patient 
lies  very  thoroughly  on  her  side  and,  particularly,  if  the  table  has  the  lon- 
gitudinal and  lateral  tip  described  on  page  30,  the  exjjansion  of  the  vagina 
■wiU  often  be  sufficient  to  enable  the  physician  unaided  to  obtain  a  good 
view  of  the  parts,  and,  dispensing  with  depressor  or  tenaculum,  introduce 
the  probe,  or  sound,  or  appli- 
cator. The  introduction  of  va- 
ginal tampons,  and  the  aj)plica- 
tion  of  tincture  of  iodine  or 
other  agents  to  the  vagina  and 
cervix,  is  thus  perfectly  feasible. 

The  whole  vagina,  except  the 
posterior  wall,  and  the  cervix  in 
its  totality  are  exposed  freely  to 
view  through  Sims'  speculum,  an  advantage  offered  by  no  other  form  of 
speculum,  and  not  to  be  undervalued.  The  cervix,  being  visible  in  its 
whole  periphery,  it  is  much  easier  to  recognize  deformities  and  injuries  of 
that  organ  through  this  speculum  than  thi*ough  any  other.     Thus,  for 


52. — Correct  Position  for  Examination  with  Sims' 
Speculum  (P.  F.  M.). 


90 


GYNECOLOGICAL    EXAMINATION. 


instance,  laceration  of  the  cervix  is  easily  recognized,  and  its  extent  and 
curability  determined  only  through  this  instrument.  This  is  done  by 
seizing  each  lip  with  a  tenaculum  from  its  vaginal  surface  and  approxi- 
mating them,  when  the  everted  cervical  mucosa  will  be  rolled  in,  and  the 
normal  shape  of  the  cervix  be  restored  ;  if  the  lips  cannot  be  approxi- 
mated, either  lateral  adhesions  or,  what  is  more  common,  cystic  and  areolar 
hyperplasia  of  the  cervix  are  present.  Thus,  a  laceration  can  readily  be 
distinguished  from  an  erosion  of  the  cervix,  in  which  latter  there  are 
obviousty  no  torn  lijDS  to  approximate.  It  is  often  possible  by  thoroughly 
separating  the  vaginal  walls  with  speculum  and  tenaculum  to  obtain  a 
view  of  a  good  portion  of  the  cervical  canal,  especially  if  the  cervix  be 
lacerated. 

The  duck-bill  speculum  may  be  used  with  equal  facility  in  the  right 
semij)rone  position,  the  directions  for  its  employment,  so  far  as  the  hands 
are  concerned,  merely  being  changed  from  left  to  right,  or  the  reverse.     In 


Fig.  53. — Expansion  of  Vagina.     Position  of  the  Uterus  and  Speculum  in  the  Knee-chest  Position  (Hegar 

and  ICaltenbach). 

cases  where  it  is  desirable  to  see  or  reach  the  right  upper  portion  of  the 
vagina,  as  in  fistulse  in  that  region,  or  the  aspiration  of  cellulitic  abscesses 
in  the  right  broad  ligament,  this  position  is  preferable  to  the  left. 

In  the  knee -chest  position,  the  Sims  speculum  is  also  a  very  useful  in- 
strument. By  lifting  the  jDerineum  with  it,  au-  and  light  are  admitted  into 
the  vagina,  which  is  distended  balloon-like,  every  fold  and  crevice  becom- 
ing effaced.  A  better  view  of  vagina  and  cei'vix  are  obtained  in  this  man- 
ner than  even  in  the  semiprone  position  ;  the  objection  to  the  knee-chest 
position  is  its  inconvenience  to  the  patient,  and  consequent  unsuitableness 
for  long  examinations.  The  speculum  is  simply  slipped  into  the  vagina 
sideways,  turned,  and  its  shank  grasped  by  one  full  hand,  which  makes 
strong  upward  traction,  while  the  forearm  rests  on  the  sacrum  as  a  ful- 
crum.    Depressor  and  tenaculum  are  generally  not  needed  to  expose  the 


EXAMINATION    WITH    THE    SPECULUM.  91 

cervix.  In  stout  women  it  is  usually  necessary  to  separate  the  nates  before 
obtaining  a  full  view.  An  examination  in  this  position  may  be  advisable 
when  it  is  desired  to  obtain  a  view  of  the  distended  vagina  (fistula,  vagi- 
nitis) ;  it  is  chiefly  employed  as  a  preparatoiy  step  to  replacing  a  retro- 
displaced  uterus  (see  chapter  on  Keplacement  of  the  Utenis),  or  introduc- 
ing a  pessary,  or  operating  on  a  vesico-vaginal  fistula. 

In  case  of  emergency  the  first  two  fingers  of  the  right  hand  may  be 
used  as  a  substitute  for  the  duck-bill  speculum,  and  a  view  of  vagina  and 
cervix  be  obtained,  or  tampons  introduced  or  removed  by  theii"  aid  in  semi- 
prone  and  knee-chest  positions. 

The  difficulties  encountered  in  making  a  specular  examination  ai-e 
chiefly  such  as  are  due  to  the  presence  of  the  hymen,  or  constriction,  or 
rigidity  of  the  vaginal  orifice  and  perineum,  or  sensitiveness  and  soreness 
of°the  parts.  The  obstacle  caused  by  these  conditions  may  be  overcome 
by  great  gentleness  and  persuasion,  the  use  of  a  very  small  speculum,  and 
previous  careful  anointing  of  the  vaginal  orifice  ;  in  aggravated  cases, 
anesthesia  may  be  required.  When  the  resistance  is  due  to  vaginismus, 
or  erosion  of  the  vulvo-vaginal  orifice,  the  repeated  application  of  a  solution 
of  nitrate  of  silver  (grs.  xv.  to  xxx.  to  the  ounce),  or  of  iodoform  or  beUadonna 
ointment  or  suppositories,  will  generally  toughen  the  parts  so  as  to  permit 
the  examination.  A  very  common  obstacle  to  a  clear  view  of  the  interior 
of  the  vagina  is  the  forcible  contraction  by  the  patient  of  the  perineo- 
vaginal muscles,  and  the  pressing  down  of  the  anterior  vaginal  walk 
Gentleness  and  persuasion  will  soon  overcome  this.  In  stout  women  a 
broader  and  shorter  speculum  is  required  to  expand  the  vagina  thoroughly 
and  bring  the  cervix  nearer  the  orifice.  If  the  vaginal  walls  are  veiy 
flabby  and  foldy,  some  difficulty  may  be  experienced  in  preventing  them 
from  obstructing  the  view  of  the  cervix ;  a  short,  broad  speculum,  a  large 
depressor,  and  downward  traction  with  the  tenaculum  will  generally  over- 
come this.  If  necessary  the  examination  may  be  made  in  the  knee-chest 
position,  and  will  then  always  be  successful. 

Modifications  and  Combinations  of  the  Sims  SpecMZimi.— Besides  the 
minor  modifications  referred  to  on  page  83,  numerous  other  contrivances 
have  been  adapted  to  Sims'  speculum,  all  with  the  view  of  supplying  the 
place  of  an  assistant.  Of  these  the  most  simple  is  that  of  Thomas,  the 
attached  sliding  depressor  of  which  is  intended  to  free  the  right  hand  ;  but 
I  have  found  the  breadth  of  the  blade  at  the  angle,  and  the  shank  holding 
the  depressor,  entirely  insufficient  to  prevent  the  overiapping  of  the  su- 
perior natis,  and  the  view  therefore  quite  as  much  obstructed  as  with  the 
plain  Sims  and  no  assistant.  The  only  advantage  of  this  instrument  is  the 
attached  depressor.  In  spare  women,  with  tense  vulva  and  vagina,  it  will 
often  be  found  serviceable. 

Greatly  more  pretentious  are  those  modifications  which  seek  to  do 
away  entirely  with  an  assistant  and  also  give  the  physician  the  use  of  both 
hands.  Numerous  devices  of  this  nature  have  been  published,  and  others, 
to  my  knowledge,  have  not  as  yet  been  laid  before  the  profession.  Per- 
haps the  most  serviceable  self-retaining  specula  are  those  of  Emmet,  Hun- 


GYNECOLOGICAL    EXAMHSTATIOlSr. 


ter,  Erich,  and  Stuclley,  the  construction  and  apphcation  of  which  is  quite 
compHcated,  and  should  be  studied  in  the  original.  The  mechanism  of 
the  majority  of  these  specula  consists  essentially  in  using  the  broad  pos- 
terior surface  of  the  sacrum  as  a  fulcrum  from  which  the  fixation  and  re- 
traction of  the  blade  is  secured.  Emmet's,  Erich's,  and  Studley's  specula  I 
have  tried  and  found  decidedly  useful.  The  objection  to  all  these  contri- 
vances, however,  it  seemed  to  me,  was  the  impossibility  of  securing  the 
upward  twist  of  the  blade  so  strongly  insisted  upon  in  my  description  of 


Fig.  54. — fetuclieys  Moaified  Sims'  Speculum.  A,  spinal  plate;  B,  sacral  plate;  C,  cross-bar;  D, 
sliding-bar ;  E,  F.  gluteal  bars ;  (?,  slotted  cap  ;  R,  speculum  ;  /,  screw  by  which  point  of  speculum  is 
varied  anteriorly  or  posteriorly  ;  K,  screw  by  which  the  perineum  is  retracted  ;  X,  eyeleted  wire  hook  for 
varying  position  of  speculum  laterally. 

the  examination  with  the  Sims,  which  twist  is  so  essential  to  the  projDcr 
illumination  of  the  vagina.  The  point  is,  that  the  hand  which  lifts  the 
superior  natis  and  labium  cannot  be  dispensed  with.  Another  objection 
is  the  preparation  required  to  adjust  these  instruments,  which  may  alai'm 
the  patient. 

There  are  but  two  combinations  of  Sims  and  another  speculum,  so 
far  as  I  know,  and  they  are  by  Dr.  Gillette,  of  New  York,  and  myself.  In 
both  of  these  instrument  a  Sims  is  combined  with  a  Nott  speculum,  and 


EXAMINATIOlSr    WITH    THE    SPECULTJ.Ar.  93 

both  are  designed  to  be  used  in  the  semiprone  position  only  when  com- 
bined, and  in  the  dorsal  or  lateral  when  the  detached  Nott  is  employed. 
The  advantages  of  Dr.  Gillette's  instrument  are  the  shortness  of  the  shank 
of  the  Nott,  when  detached,  and  the  curve  (Van  Buren's)  of  the  other 
blade,  which  renders  it  sei-viceable  for  rectal  examination.  The  advantage 
of  my  instrument,  on  the  other  hand,  is  the  ability  to  enlarge  the  antero- 
posterior expansion  of  its  vulvar  orifice  by  shding  foi-ward  the  anterior 
branches  (the  ant.  j)ost.  diameter  of  the  orifice  then  measures  three  to  two 
inches  unenlarged,  the  transvei'se  diameter  two  inches),  an  advantage  not 
to  be  undervalued,  as  it  not  only  gives  more  room  but  fixes  the  whol'? 
instrument  more  firmly  in  the  vagina.  In  both  instruments  the  Nott  is 
detachable,  and  the  screws  and  anterior  branches  can  be  removed  so  as  to 
form  a  plain  Sims.  We  thus  have  a  combined  Sims  and  Nott,  a  simple 
Nott  and  a  simple  Sims  in  one  instrument.  I  can  testify  to  the  utility  and 
simplicity  of  my  instrument,  having  even  frequently  found  it  to  rest  so 
firmly  on  the  inferior  buttock  when  fully  expanded  as  to  enable  me  to 
loosen  my  hold  on  the  handle  and  use  both  hands  for  manipulation.  The 
objection  to  these  instruments  is  the  pain  which  the  enormous  distention 
of  the  vaginal  pouch  causes  (three  and  a  half  inches  at  tip  of  blades  of  my 
speculum)  ;  but  this  objection  is  overcome  by  not  separating  the  blades 
to  their  limit.  An  instrument  similar  in  design  has  also  been  devised  by 
Dr.  Jenks,  of  Chicago.  It  is  natural  that  every  inventor  should  be  preju- 
diced in  favor  of  his  own  instrument  and  that,  indeed,  he  should  succeed 
better  with  it  than  any  one  else.  Being  myself  guilty  of  a  speculum  (for 
mine  was  devised  independently  and  before  I  knew  of  Dr.  Gillette's)  it  will 
not  seem  invidious  in  me  when  I  say  that  all  these  complicated  modified 
Sims  specula  have  not  succeeded  in  becoming  popular,  and  are  chiefly 
used  by  their  inventors.  That  this  is  not  a  proof  of  their  worthlessness,  I 
am  firmly  convinced.  For  my  part,  if  I  should  not  succeed  in  exposing 
the  vagina  and  cervix,  as  I  wish,  and  using  whatever  manipulations  are 
necessary  through  Thomas'  or  my  combination  speculum,  I  should  think  it 
useless  to  try  one  of  the  first  described  complicated  contrivances,  and  at 
once  secure  competent  assistance. 

Other  Forms  of  Specula. — I  shall  describe  but  two  other  specula,  which 
come  under  none  of  the  exact  heads  ah-eady  mentioned,  viz. :  Neugebauer's 
double-crescent  speculum  as  modified  by  Barnes,  and  Simon's  gutter- 
speculum  with  vaginal  holders.  For  some  years  joast  I  have  had  less  and 
less  occasion  to  use  either  the  valvular  or  combination  Sims  specula,  find- 
ing the  ordinary  Sims,  or  the  one  with  a  buttock-flange  demised  by  me,  all- 
suflicient.  Neugebauer's  double  crescent  speculum  (or  double  shoe-horn 
speculum,  as  it  might  be  called),  can  be  used  either  on  the  back  or  in  the 
lateral  position,  the  posterior  blade  being  introduced  first  and  the  anterior 
shpped  into  it.  Both  hands  are  required  to  hold  the  blades,  which  will  do 
for  diagnosis,  but  renders  the  instrument  imsuitable  for  operations  unless 
an  assistant  be  present  to  hold  one  blade.  What  its  advantage  over  Sims' 
speculum  is  does  not  appear  to  me,  and  I  do  not  see  in  what  it  surpasses 
our  best  lai-ge-mouthed  bivalves.     The  necessity  for  its  invention  therefore 


94 


GYISTECOLOGICAL    EXAMINATION-. 


seems  doubtful,  and  I  question  whether  more  than  two  or  three  gynecolo- 
gists in  this  country  use  it.     However,  as  a  bivalve,  which  it  really  is,  I 

can  conceive  of  its  being  useful  in 


many  cases,  chiefly  where  very  great 
distention  of  the  cul-de-sac  is  de- 
sired, or  (it  comes  in  sets  of  single 
blades,  from  one  to  four,  each 
blade  having  a  different  size  at 
either  end)  when  the  vaginal  orifice 
is  very  narrow  and  only  one  blade 
can  be  introduced  at  a  time.  An 
objection  must  always  be  the  im- 
mobility of  the  cervix.  Barnes 
speaks  highly  of  it.  I  have  never 
used  it,  nor  felt  the  want  of  it. 

The  construction  and  mode  of 
employment  of  Simon's  specula  and 
holders  is  shown  in  the  accompany- 
ing diagrams.  The  specula  and 
plates  for  supporting  the  anterior 
wall  come  in  sets  of  five  different 
sizes,  which  are  attached  to  the 
handles ;  the  flat  holders  with  long  handles  are  used  to  retract  the 
lateral  walls,  of  the  vagina.     The  patient  occupies  the  gluteo-dorsal  posi- 


FlGS. 


56.— Simon's    Vaginal 
Ke  tractor. 


Specula 


Fig.  57.— Position  for  and  Manner  of  ITsing  Simon's  Specula. 


tion,   one   assistant  holds   the   perineal  speculum,   another   the   left  leg 
and  the  anterior  plate,  and  the  left  lateral  retractor ;   a  third  assistant 


EXAMINATION    WITH    SOUND    AND    PROBE.  95 

the  other  leg  and  the  right  lateral  retractor.  An  excellent  view  is  thus  ob- 
tained of  the  cervix  and  vaginal  pouch,  particularly  of  the  anterior  wall. 
This  position  enabled  Simon  to  attain  his  marvellous  results  in  operating 
on  large  vesico-vaginal  fistulae,  and  to  cure  many  cases  of  prolapsus  uteri 
by  his  posterior  coljDorrhaphy  operation.  But  it  is  manifestly  much  less 
convenient  than  the  Sims  position  for  the  assistants,  more  of  whom  are 
required,  and  the  number  of  instruments  needed  is  also  greater  ;  and  I  can 
conceive  of  no  operations  on  cervix  or  vagina  which  can  be  performed 
more  easily  through  the  Simon  specula  than  through  the  Sims,  excejDt  only 
those  'on  the  posterior  wall  of  the  vagina,  in  which  Simon's  method  is  in- 
dispensable. Therefore,  the  Simon  instruments  and  position  have  not 
become  popular  in  this  country  for  cervix  or  fistula  operations. 

A  very  ingenious  and  practical  contrivance  has  been  devised  by  Fritsch, 
of  Breslau,  for  supporting  and  steadying  the  separated  legs  of  the  patient, 
and  retaining  the  modified  Simon's  specula,  in  operations  on  the  cervix. 
But  I  fail  to  see  the  necessity  for  such  assistant-saving  devices  in  any  com- 
munity short  of  a  deserted  island.  As  a  rule,  wherever  such  opei*ations 
are  to  be  perfoi-med,  sufiicient  assistance  can  readily  be  obtained  free  of 
expense,  and  trained  gynecologists  are  by  no  means  essential  to  hold  a 
speculum  or  squeeze  a  sponge. 

C.  Examination  of  the  Uterus  ivith  Sound  and  Probe. 

There  are  two  varieties  of  uterine  sounds,  the  flexible  and  the  inflexible. 

The  flexible  are  made  of  whalebone  or  rubber  (elastic),  or  silver  or  cop- 
per ;  if  the  latter,  generally  silver-  or  nickel-plated.  Of  these  flexible  metal 
sounds  there  are  again  two  kinds  :  1,  Such  as  are  so  flexible  as  to  bend  at 
the  shghtest  obstacle  and  yield  to  the  pressure  caused  by  an  attempt  to 
replace  a  displaced  uterus  ;  and  2,  such  as  are  stiff,  but  can  be  moulded  by 
the  finger,  and  retain  the  shape  and  curve  given  them  despite  any  ordi- 
nary obstacle  encovmtered,  such  as  a  sharp  flexion,  and  permit  the  reposi- 


FiG.  58.— Simpson's  Stiff  Sound. 

tion  of  a  non-adherent  uterus  without  straightening  out.  The  representa- 
tive of  the  former  class  is  the  Sims,  that  of  the  latter  the  Simpson 
sound. 

Of  these  two,  I  prefer  and  always  use  the  stiffly  flexible  Simjison 
sound,  because  it  is  thicker  than  the  Sims  and  therefore  less  likely  to 
catch  in  the  folds  of  the  cervical  mucous  membrane,  but  chiefly  because  a 
flexible  sound  of  soft  metal  is  difficult  to  introduce  and,  yielding  to 
every  obstacle  and  following  every  cm-ve  of  the  uterine  canal,  gives  but 
little  information  as  to  the  direction  of  the  canal  and  the  mobility  of  the 
uterus  ;  that  is  to  say,  when  it  is  introduced  by  the  touch  only,  which  is 
the  manner  in  which  I  generally  use  the  sound  ;  if  through  a  Sims'  specu- 


96  GYNECOLOGICAL    EXAMINATIOlSr. 

lum,  the  liigMy  flexible  sound  or  probe  is  preferable  and  safer.  The  pre- 
cautions always  to  be  observed  in  using  the  stiff  sound  will,  I  think,  justify 
my  preference  for  it.  The  Simpson  sound  is  graduated  in  quarter  inches 
and  inches  for  the  whole  length  of  its  shaft,  and  has  a  small  knob  at  a  dis- 
tance of  two  and  a  half  inches  from  the  point,  this  being  the  average 
length  of  the  normal  uterine  cavity  ;  the  uterine  portion  of  the  sound  is 


'^\\.'atv*^vo\ . 


Fig.  59.— Sims'  Flexible  Sound. 


not  graduated  in  order  to  be  perfectly  smooth.  The  point  is  blunt  and 
slightly  expanded. 

Another  thicker  sound  of  uniform  size  all  through  has  been  devised  by 
Peaslee,  who  used  it  to  dilate  and  preserve  patulous  the  uterine  canaL 
It  is  also  graduated,  and  is  very  useful  besides,  in  replacing  a  dislocated 
uterus,  as  its  thick  tip  is  less  likely  to  injure  the  fundus. 

Very  thin,  flexible,  or  elastic  rods  made  of  pure  silver,  whalebone,  or 
hard  rubber,  are  called  probes,  and  are  used  for  precisely  what  their  name 
implies.     While  a  sound  carries  a  more  sonorous  tone  and  purpose  with 


Fig.  60.— Peaslee's  Thiol:  Sound. 

it,  the  probe  is  simply  meant  to  wind  its  way  into  the  uterine  cavity  and 
gently  ascertain  the  direction  of  the  canal  and  its  length. 

The  probe  ordinarily  in  use  is  that  of  Sims  or  Emmet ;  it  is  so  flexi- 
ble that  it  is  almost  impossible  to  introduce  it  into  the  uterine  cavity  with- 
out a  sjDeculum,  and  it  bends  at  the  slightest  impediment  in  the  ca- 
nal. It  is  of  the  thickness  of  an  ordinary  mandrin  of  an  elastic  catheter, 
and  provided  with  a  small  knob  at  the  tip.  The  whalebone  or  hard-rub- 
ber probes  are  similar  in  size  and  shape,  and  elastic  instead  of  flexible. 
Probes  are  not  graduated.     All  probes  are  to  be  used  through  a  speculum. 


Fig.  61. — Sims-Emmet's  Flexible  Silver  Probe, 


always  preferably  the  duck-bill.  The  regulation  length  of  sounds  and 
probes  is  one  foot  from  tip  to  tip,  but  some  elastic  sounds  are  made  longer 
for  use  in  cases  of  elongation  of  the  uterine  cavity,  as  in  fibroids  of  the 
uterus. 

A  flat  whalebone  sound  with  a  broad  knob  at  the  tip,  and  a  long  hard- 
rubber  probe,  both  attached  to  a  handle,  have  been  devised  by  Dr. 
Thomas,  for  the  diagnosis  of  the  existence  and  attachment  of  submucous 
uterine  fibroids.     These  sounds  adapt  themselves  to  the  naiTOw  space 


INDICATIONS    AND    PRECAUTIONS    FOE    USE    OF    SOUND.         97 

between  the  projecting  tumor  and  the  opposite  uterine  wall,  and  by  tbe 
direction  which  they  take  give  the  examiner  an  idea  of  the  presence  and 
extent  of  the  tumor. 

A  jointed  spiral  sound  has  been  invented  by  Dr.  E.  W.  Jenks,  of  Chi- 
cago, for  use  in  tortuous  uterine  canals  (fibroids,  etc.).  It  is  hollow,  and 
may  also  be  used  as  a  catheter. 

Indications  and  Precautions  for  the  Use  of  the  Sound. 

The  indications  for  using  the  sound  or  probe  may  be  summed  up  in 
the  following  sentence  :  Whenever  any  information  is  to  be  obtained,  and  a 
j^revious  careful  oral  and  bimanual  examination  reveals  no  counterindicalion, 
particularly  if  it  be  a  first  examination,  the  sound  may  be  passed  into  the 
iderus.  The  chief  indication,  therefore,  is  the  chance  of  ascertainino- 
something  which  may  be  necessary  or  valuable  for  the  physician  to  know. 
This  chance  will,  of  course,  present  itself  most  frequently  in  patients 
whom  we  have  not  seen  before,  and  of  whose  local  condition  we  are 
totally  ignorant.  Besides,  it  seems  to  me  that  the  same  reason  enunci- 
ated as  an  indication  for  a  specular  examination,  applies  equally  to  the 
introduction  of  the  sound,  viz.,  that  it  is  our  duty  to  emj^loy  eveiy  means 
at  our  command  to  obtain  a  thorough  knowledge  of  the  patient's  con- 
dition, provided  always  that  such  means  are  not  likely  to  be  injurious. 
Acting  on  this  princijDle  and  carefully  selecting  my  cases  and  eliminat- 
ing those  in  whom  the  least  counterindication,  or  suspicion  of  one 
(to  be  stated  hereafter)  existed,  I  have  been  in  the  habit  since  the  be- 
ginning of  my  gynecological  practice,  fully  sixteen  years  ago,  of  explor- 
ing the  cavity  of  the  uterus  with  the  sound  or  probe  in  every  patient  who 
came  to  me  for  a  first  consultation.  I  have  thus  introduced  the  sound  in  at 
least  fifteen  thousand  cases,  besides  certainly  as  many  more  times  in  women 
upon  whom  it  was  passed  repeatedly  either  for  diagnosis  or  for  joractice, 
and  have  for  the  last  ten  years  taught  my  private  students  to  introduce  it 
as  soon  as  they  had  acquired  sufficient  dexterity — and  in  all  these  cases 
I  have  still  to  meet  with  the  first  case  in  which  inflammatory  reaction  fol- 
lowed the  sounding,  or  anything  more  than  slight  uterine  colic  or  mod- 
erate shock  resulted  from  it.  While  temporary,  suprapubic  pain  was  not 
unfrequent,  uterine  colic  was  rare,  and  I  have  met  with  but  two  cases  in 
which  colic  and  shock  lasting  several  days  ensued,  and  in  both  of  these 
cases  the  patient  confessed  afterward  that  the  sound  had  been  used  once 
before  by  other  physicians — as  it  happened,  expert  gynecologists — with  the 
like  result.  In  no  instance  but  these  two  have  I  had  occasion  to  regret  its 
use — except,  I  confess,  several  cases  of  vei'y  early  pregnancy  in  which  this 
routine  sounding  induced  miscarriage.  Thus,  I  once  sounded  a  lady  at 
her  first  visit  who  had  menstruated  exactly  three  weeks  previously,  and 
found  no  obstacle  to  the  sound  ;  to  be  sure,  the  uterus  measured  three 
and  a  quarter  inches,  but  her  youngest  child  was  but  five  months  old. 
Still,  as  events  proved,  the  lady  was  two  to  three  weeks  pregnant  at  the 
time  of  sounding,  began  to  flow  gently  several  days  later,  and  miscaiTied 
7 


98  GYNECOLOGICAL   EXAMINATION. 

in  about  a  month,  the  ovum  presenting  the  appearance  natural  to  sis 
weeks.  In  several  cases  intentional  misstatement  was  m.ade  as  to  the  date 
of  the  last  menstruation.  But,  on  the  other  hand,  I  have  repeatedly  known 
the  pregnancy  to  go  on  after  a  sounding  unwittingly  performed.  Notwith- 
standing this  occasional  tolerance,  I  should  deprecate  most  emphatically 
the  practice  recently  proposed  by  a  Western  gynecologist  to  diagnose  early 
pregnancy  by  the  elastic  resistance  offered  to  the  point  of  the  sound  as  it 
is  passed  toward  the  fundus. 

I  am  aware  that  in  thus  counselling  the  frequent  introduction  of  the 
sound  I  am  advising  a  course  different  from  that  usually  recommended. 
Since  the  introduction  of  the  sound  by  Simpson,  who  was,  of  course,  its 
earnest  advocate,  there  have  been  frequent  controversies  as  to  the  utility 
and  dangers  of  the  instrument.  The  majority  of  modei-n  gynecologists 
advise  its  rational,  careful  employment,  and  hold  that  the  present  devel- 
opment of  the  methods  of  bimanual  examination  render  the  sound  much 
less  necessary  than  formerly.  That  is  precisely  what  I  also  believe  and 
practice.  Use  it  only  when  necessakt  and  devoid  of  danger  ;  and  it  is  pre- 
cisely during  a  first  examination  that  I  claim  for  it  the  reason  of  necessity  and 
utility.  I  wish  it  distinctly  understood  that  I  do  not  advise  its  use  in  every 
case,  even  though  it  probably  may  do  no  harm  ;  that  I  carefully  exclude, 
so  far  as  possible,  all  counterindicating  circumstances  and  conditions  ; 
further,  that  I  should  permit  its  use  in  the  cases  described  by  me  only  by 
persons  experienced  in  its  manipulation,  and  should  forbid  it  to  all  such 
who  either  are  not  experts  in  indagation  and  bimanual  examination  or  are 
novices  with  the  sound.  With  these  restrictions  I  think  its  frequent  em- 
ployment in  the  cases  mentioned,  and  after  the  manner  to  be  described  by 
me,  both  justifiable  and  useful.  I  need  scarcely  say  that  the  greatest  care 
and  delicacy  are  indisj)ensable  features  of  its  introduction.  The  familiarity 
with  the  physical  examination  of  the  female  sexual  organs  and  the  previous 
knowledge  of  the  position  of  the  uterus  and  the  direction  of  its  canal, 
which  I  thus  make  indispensable  conditions  for  the  use  of  the  sound,  will 
naturally  restrict  its  use  to  those  gentlemen  whose  touch  has  been  sviffi- 
ciently  educated  to  enable  them,  to  practise  gynecology  intelligently.  AU 
others  should  either  avoid  the  specialty  or  hasten  to  improve  their  acquaint- 
ance with  its  rudiments.  It  was  for  the  purpose  of  fitting  gentlemen  to  use 
the  sound  in  cases  where  it  alone  may  settle  the  diagnosis  that  I  for  years 
ran  the  risk  necessarily  attending  its  use  for  practice  by  inexperienced 
hands  in  my  private  classes. 

The  p)recautions  to  be  obseiwed  in  using  the  uterine  sound  or  probe  are 
chiefly  comprised  in  the  two  words :  dexterity  and  gentleness.  No  force 
whatever  should  be  used  either  in  slipping  the  sound  into  the  uteiine 
cavity,  or  in  manipulating  or  rotating  it  while  there.  As  a  rule,  the  intro- 
duction should  give  pain  only  when  the  tip  passes  through  the  always 
narrower  internal  os  or  touches  the  usually  tender  fundus.  Neither 
should  it  be  followed  by  a  show  of  blood,  except,  perhaps,  when  it  is 
necessary  to  work  the  point  through  the  internal  os,  or  the  endometrium 
is  hyperemic.     If  an  obstruction  is  met  with  at  any  point  of  the  canal, 


INDICATIONS    AND    PRECAUTIONS    FOR    USE    OF    SOUND. 


99 


Fig. 


Fibroid   in   Anterior  'Wall  of  Tlterua  Simulating 
Anteflexion  (P.  F.  M.). 


particularly  at  the  os  internum,  which  the  gentle  manipulations  of  a 
practised  hand  cannot  overcome,  the  attempt  should  be  abandoned  ;  at 
least,  if  persisted  in,  it  should 
not  be  considered  a  simple 
diagnostic  measure.  If  severe 
pain  is  caused,  if  the  patient 
shows  signs  of  faintness  or 
collapse,  the  sound  should  be 
at  once  withdrawn,  and,  if 
necessary,  the  proper  restora- 
tives administered.  A  precau- 
tion especially  to  be  observed 
is  to  pass  the  sovmd  forward 
very  carefully  after  its  tip  has 
passed  the  internal  os,  in  order, 
first,  not  to  give  pain  by  strik- 
ing sharply  against  the  fun- 
dus, and,  second,  not  to  risk 
perforating  the  uterine  wall. 
It  must  not  be  thought,  be- 
cause the  tissue  of  the  uterus 
is  ordinarily  tough  and  its 
closely  interlaced  fibres  pos- 
sess great  power  of  resistance,  that  this  accident  is  impossible.  There  are 
certain  conditions  of  the  uterus  in  which  the  organ  has  retained  the  soft, 

pulpy  texture  of  the  jjuerperal 
state,  is  in  fact  subinvoluted, 
or  in  which  such  a  change 
arises  independently  of  par- 
turition, so-called  marciditas 
uteri,  in  which  the  sound  has 
been  known  to  perforate  the 
fundus  with  the  greatest  facil- 
ity, even  in  experienced  hands, 
and  appear  at  the  umbihcus, 
to  the  horror  of  the  ojDerator. 
That  such  accidents  have  thus 
far,  strange  to  say,  been  fol- 
lowed by  no  evil  consequences, 
should  scarcely  lead  us  to  neg- 
lect every  possible  precaution 
to  avoid  them. 

As  a  rule,  it  is  not  advis- 
able, because  more  or  less  pain- 
ful and  hazardous,  to  move  the 
uterus  about  with  the  sound, 
the  fulcrum  for  which  is  the  mucous  membrane  of  the  fundus.     This 


Fig.  63.— Fibroid  in  Posterior  Wall  of  Uterus    Simulating 
Retroflexion  (P.  F.  M.). 


100  GYNECOLOGICAL    EXAMINATIOJST. 

nianeu-vxe  is  often  employed,  particularly  in  replacing  a  dislocated  uterus, 
or  in  producing  the  opposite  displacement ;  but  a  certain  amount  of  risk 
always  accompanies  it,  and  it  is  not  to  be  recommended  for  general  em- 
ployment. In  experiened  hands,  however,  fully  competent  to  gauge  the 
amount  of  force  which  the  average  fundus  uteri  will  stand  without  injury, 
the  sound  may  under  certain  circumstances  (to  be  hereafter  described)  be 
employed  as  a  repositor. 

In  patients  who  are  still  suffering  or  have  recently  suffered  from  uterine 
hemorrhage,  the  passage  of  the  sound  or  probe  may  be  indicated  with  a 
view  to  ascertaining  the  length  and  dimensions  of  the  uterine  cavity  and 
the  possible  presence  of  an  intra-uterine  tumor  (submucous  fibroid  or 
polypus)  as  the  cause  of  the  flow  ;  but  unusual  care  should  be  exercised 
in  order  not  to  renew  or  increase  the  hemorrhage. 

In  chronic  pelvic  peritonitis  or  celluHtis  of  the  adhesive  type,  it  may 
occasionally  be  permissible  to  introduce  the  sound,  but  only  when  the 
uterine  canal  is  patulous  and  straight  and  the  sound  glides  in  without  the 
least  effort. 

The  information  to  be  obtained  by  the  inti'oduction  of  the  sound  or 
probe  is  the  following  :  the  patency  of  the  external  os,  the  dimensions  of 
the  cervical  canal,  the  size  of  the  internal  os,  the  dimensions  of  the  cavity 
of  the  body  of  the  uterus,  therefore  the  dimensions  of  the  whole  uterine 
canal.  Further,  the  sensitiveness  of  the  internal  os  and  fundus  uteri  ;  the 
direction  and  course  of  the  uterine  canal,  and  consequently  the  position  of 
the  body  and  fundus  of  the  uterus.  Further,  the  mobility  of  the  uterus, 
and  consequently  the  presence  or  absence  of  adhesions  and  obscure  remains 
of  pelvic  peritonitis  or  celluhtis.  Fui-ther,  the  existence  of  endotrachelitis 
or  endometritis  by  the  character  of  the  discharge,  if  any,  issuing  from  the 
external  os  and  attached  to  the  finger  or  sound  on  their  withdrawal  from 
the  vagina.  The  o]pening  of  the  external  and  internal  os,  possibly  the 
straightening  of  the  canal  in  flexions,  by  the  sound  may  thus  give  exit  to 
retained  secretion. 

Tlie  presence  of  an  intra-uterine  growth  may  be  detected  by  one  or  the 
other  variety  of  sounds  or  probes.  The  occurrence  of  actual  hemorrhage 
after  the  gentle,  easy  introduction  of  the  sound  may  indicate  an  inflamed 
or  congested  condition  of  the  endometrium,  or  the  presence  of  granula- 
tions or  vegetations,  or  of  a  tumor  ;  in  conjunction  with  other  pelvic 
symptoms  (lancinating  pain,  cachexia),  perhaps,  uterine  sarcoma.  A 
few  drops  of  blood  very  commonly  follow  even  careful  sounding  and  have 
no  practical  significance.  A  rather  free  bleeding  may  denote  a  hyperemic 
condition  of  the  endometrium,  or  a  chronic  endometritis.  A  tortuous 
course  of  the  uterine  canal  is  best  detected  by  a  flexible  probe. 

It  should  be  distinctly  understood  that  the  sound  is  never  to  be  intro- 
duced until  a  careful  vaginal  and  bimanual  examination  has  preceded  it, 
upon  the  results  of  which  the  advisability  or  necessity  for  the  sound  must 
depend.  Also,  that  the  position  of  the  uterus  should  have  been  previously 
ascertained  by  indagation,  and  the  sound  is  to  be  relied  upon  for  this  pur- 
pose only  in  the  comjDlications  presently  to  be  mentioned.     He  who  uses  the 


INDICATIONS    AND    PEECAUTI0N3    FOR    USE    OF    SOUND.      101 


Fig.  64. — Showing  Normal  Length 
of  Uterine  Cavity  in  Ovarian  Tumor 
(P.  F.  M.). 


sound  to  detect  the  position  of  the  fundus  uteri  without  first  having  failed 

to  find  it  by  bimanual  examination,  has  entirely  mistaken  the  scope  of  the 

instrument  or  is  ignorant  of  palpation. 

Aside  from  those  cases  where  the  introduction  of  the  sound  may  prove 

of  possible  utility,  there  are  numerous  instances  in  which  it  alone  can  re-. 

veal  the  whereabouts  of  the  body  of  the  uterus 

and  settle  the  diagnosis.     Such  are  all  cases 

in  which  the  condition  of  the  abdominal  wall 

prevents  effectual  bimanual   examination,  as 

when  the  presence  of  an  ante-  or  a  retrocervi- 

cal  tumor  simulates  an  ante-  or  a  retroflexion, 

and  the  situation  of  the  fundus  cannot  be  de- 
tected through  the  abdominal  wall ;  the  sound 

then  shows,  by  its  forward  or  backward  or 

straight  direction,  whether  the  case  is  one  of 

ante-uterine  tumor  or  anteflexion  (see  Figs.  17 

and  62),  or  of  retro-uterine  tumor  or  retro- 
flexion  (see  Figs.   20   and  63).      Further,  in 

large  abdominal    tumors    the  sound  usually 

settles  (there  are  exceptions  to  this  rule)  the 

diagnosis  between  ovarian  tumors,   in  which 

the  uterine  canal  is  seldom  elongated,  and  the 

fibro-cysts  of  the  uterus,  in  which  the  uterine  cavity  may  attain  the  length 

of  seven  or  eight  inches. 

Counterindications  and  Dangers. — There  are  two  conditions  which  ab- 
solutely counterindicate  the  introduction  of  the  sound  or  probe,  and  these 

are  :  1,  A  suspicion  of  pregnancy,  i.e.,  the  missing  of  a  menstrual  period  or 
some  other  jprominent  sign  ;  and  2,  the  presence 
of  acute,  subacute,  or  even  chronic  inflammation 
of  the  pelvic  cellular  tissue  or  peritoneum,  and 
acute  inflammation  of  the  uterus.  If  a  patient 
reports  having  missed  a  period,  even  if  she  be  but 
a  few  days  beyond  the  time,  beware  of  introducing 
the  sound.  Even  with  this  precaution,  as  ah'eady 
related,  an  accident  may  occur,  for  which  certainly 
the  physician  is  not  to  blame  if  the  sounding  took 
place  before  the  time  of  the  expected  period.  Pa- 
tients will  often  misinform  the  physician  as  to  the 
date  of  their  last  period,  for  the  precise  purpose 
of  inducing  him  to  do  something  which  may  bring 
about  a  miscarriage  ;  the  previous  bimanual  ex- 
amination should  have  shown  the  size  of  the  ute- 

FlG.   65. — Showing    Elongation  ,        .    . 

of  Uterine  Cavity  in  Interstitial  rus,  and  led  the  physiciau  to  suspect  pregnancy. 
But  it  should  be  stated  in  justification  of  the  not 
altogether  unknown  accidental  production  of  abortion  by  experts  as  well 
as  non-specialists  that  the  diagnosis  of  early  pregnancy,'  from  six  to  ten 
weeks,  may  be,  and  at  the  first-named  period  always  is,  a  question  of 


102  GYNECOLOGICAL    EXAMII^ATION". 

great  difficulty  or  impossibility,  requiring  the  most  delicate  and  practised 
touch.  In  areolar  hyperplasia  a  shght  enlai'gement,  con-esponding  to  a 
five  to  seven  weeks'  pregnancy,  may  be  almost  imperceptible,  and  if  the  ab- 
dominal walls  are  thick  or  rigid,  cr  the  uterus  shghtly  retroverted,  it  is 
generally  impossible  to  grasp  the  body  of  the  uterus  between  the  fingers 
and  accurately  determine  its  outline.  The  overlooking  of  pregnancy  up  to 
eight  weeks,  and  the  accidental  production  of  abortion  by  sounding  may, 
therefore,  in  the  exceptional  cases  mentioned,  be  excusable,  and  has  prob- 
ably happened  once  or  oftener  to  eveiy  experienced  gynecologist.  But  it 
is  excusable  only  when  all  the  proper  means  of  avoiding  such  a  mistake 
have  been  employed.  I  have  ah-eady  stated  that  the  introduction  of  the 
sound  for  the  diagnosis  of  pregnancy  (the  diagnosis  being  made  by  the 
aiTest  of  the  sound  by  a  soft  elastic  body  before  entering  its  normal  dis- 
tance) is  entirely  rejDrehensible.  Besides,  a  diagnosis  cannot  surely  be 
made  in  this  manner,  as  the  sound  is  quite  as  Hkely  to  slip  between  uter- 
ine wall  and  membranes  to  a  depth  even  greater  than  normal,  as  to  be 
arrested  at  the  internal  os  by  the  ovisac. 

A  probe  will  naturally,  by  its  small  size  and  flexibility,  produce  less 
irritation  than  a  sound,  but  it  should  be  equally  tabooed  in  the  cases 
named. 

The  other  counterindication,  uterine  or  pelvic  inflammation,  must  have 
been  detected  by  the  finger,  and  is  quite  as  absolute  as  suspected  preg- 
nancy. Only  in  very  old  cases  of  cellulitis  or  peritonitis,  in  which  indura- 
tions and  contractures  in  the  pelvic  cellular  tissue  are  the  sole  signs  of 
the  long  distant  inflammation,  in  which,  in  fact,  those  residues  have  taken 
on  a  fibrous  or  cicatricial  character,  may  the  cautious  introduction  of  the 
sound  and  chiefly  of  the  probe  be  justifiable  ;  such  a  course  may  be  neces- 
sary when  it  is  important  to  decide  between  a  retro-uterine  tumor  (adhe- 
rent fibroid,  or  ovary,  or  celluhtis) ;  and  an  adherent  retroflexed  fundus 
uteri.  Old  "  chronic  metritis,"  so-called,  subinvolution  or  areolar  hyper- 
plasia, and  chronic  or  subacute  endometritis,  do  not  of  course  counter- 
indicate  the  sound. 

The  dangers  attending  the  introduction  of  the  sound  are,  the  produc- 
tion of  uterine  colic  or  actual  collapse  from  shock — a  temporary  affair — 
and  of  inflammatory  reaction  in  the  serous  or  cellular  tissue  of  the  pelvis. 
Uterine  colic  is  not  a  \evj  uncommon  result,  and  generally  lasts  but  a  few 
hours  or  less,  and  passes  away  without  further  injury.  Collapse  from 
shock  is  rare  ;  I  have  never  met  with  it  from  sounding,  but  several  times 
from  a  medicated  application  to  the  endometrium.  A  fatal  case  of  shock 
from  sounding  is  not  known  to  me.  It  must  be  remembered  that  every 
gynecological  manipulation  is  attended  with  a  certain  amount  of  risk  and 
danger  ;  even  a  simj)le  digital  examination  has  been  followed  by  se^Dtice- 
mia  originating  from  a  scratch  of  the  cervix  by  the  nail,  and  a  severe  peri- 
tonitis has  resulted  from  the  gentle  compression  of  the  peritoneum  exer- 
cised during  a  bimanual  examination.  Bat  such  accidents  are  the  rare 
exception,  and  if  we  were  to  avoid  eueri/  interfei*ence  with  the  female  sexual 
organs  because  an  accident  may  possibly  happen,  we  should  simj)ly  have  to 


INDICATIOlSrS    AND    PRECAUTIONS    FOR    USE    OF    SOUND.      103 

give  up  the  local  treatment  of  those  organs  entirely.  Knowing  the  possi- 
bility of  such  an  unexpected  accident,  we  should  forestall  all  reproach  by 
employing  the  greatest  care  and  delicacy. 

A  pelvic  peritonitis  or  cellulitis  tnaij  follow  any  sounding,  as  it  may  any 
intra-uterine  application,  or  even  a  cauterization  of  the  cervix.  Therefore 
it  is  always  wise,  after  having  for  the  first  time  sounded  a  patient  whose 
peculiarities  you  are  not  familiar  with,  to  advise  her  to  remain  quiet  for 
several  hours  after  or  even  for  the  whole  day,  until  all  probability  of  re- 
action has  disappeared.  Indeed,  it  is  advisable,  after  every  sounding  or 
intra-uterine  application,  even  in  old  patients,  to  direct  them  to  remain  in 
the  anteroom  for  some  time,  one-half  or  one  hour,  before  leaving,  and  I 
have  in  several  instances  been  called  to  restore  ladies  from  temporal-}'  faint- 
ness  following  applications.  Such  attacks  are  not  always  purely  physical  in 
origin,  but  frequently  ai'ise  from  a  hysterical  tendency.  Thus  I  have  seen 
patients  go  almost  into  a  convulsion,  or  break  out  into  a  fit  of  weeping,  on 
the  passage  of  the  sound  through  the  internal  os,  symptoms  which  sub- 
sided as  soon  as  the  sound  was  withdrawn  and  were  followed  by  no  reac- 
tion whatever,  thus  showing  their  purely  nervous  nature.  I  have  abeady 
stated,  under  Precautions,  that  the  fundus  uteri  has  repeatedly  been  per- 
forated by  the  sound  in  experienced  hands,  the  uterine  tissue  in  these 
cases  being  unusually  tender  ;  also,  that  ordinarily  no  bad  results  followed 
the  accident.  Some  observers  believed  that  the  unexpected  entrance  of 
the  sound  to  the  handle,  and  the  appearance  of  the  point  near  the  umbili- 
cus was  to  be  explained  by  its  having  been  passed  into  and  through  the 
Fallopian  tube.  While  this  probably  may  occur  where  the  uterine  mouth 
of  the  tube  is  patulous,  the  investigations  of  Liebmann,  of  Trieste,  have 
shown  that  the  chances  are  greatly  in  favor  of  the  perforation.  He  found 
that  of  one  hundred  fresh  uteri,  twenty-three  were  perforated  by  the  sound 
very  easily,  forty-two  easily,  eleven  with  but  shght  force,  and  in  twenty- 
four  only  was  actual  force  required  ;  of  these  last,  eleven  uteri  were  hyper- 
plastic and  thirteen  normal.  As  a  rule,  the  uteri  of  post-climacteric 
women  were  more  easily  perforated.  Sims'  flexible  sound  was  able  to 
perforate  all  but  the  more  rigid  walls.  When  there  is  reason  to  suspect  a 
friable  condition  of  the  uterine  tissue  (subinvolution,  displacement,  with 
venous  congestion,  fatty  degeneration — judging  from  other  organs — or  in 
anemia — senile  atrophy,  etc. )  the  sound  should  either  not  be  passed  at  all, 
or  a  flexible  probe  or  bougie  substituted.  Even  though  in  the  cases 
reported  the  perforation  did  not  prove  injurious,  it  can  scarcely  be  con- 
sidered a  harmless  matter  thus  to  injure  the  peritoneum,  and  all  proper 
precautions  should  be  adopted  to  avoid  it. 

From  what  has  already  been  said  it  is  apparent  that  the  introduction 
of  a  flexible  probe  or  bougie  is  much  less  irritating  and  less  likely  to  j)i"Ove 
injurious  in  susceptible  cases  than  the  sound.  The  probes  and  bougies, 
however,  requiring  to  be  passed  through  a  speculum,  do  not,  in  my  opin- 
ion, give  as  much  information  as  the  sound. 

Ilanner  of  Introducing  the  Sound. — I  always  introduce  the  sound  by  the 
touch  (and  not  through  the  speculum)  whenever  a  previous  digital  exami- 


104  GYNECOLOGICAL    EXAMHSTATION. 

nation  lias  shown  me  its  probable  feasibility,  utility,  and  innocuousness. 
I  prefer  to  be  guided  by  my  finger  in  this  maneuvre  rather  than  by  the  eye, 
for  with  the  finger  against  the  cervix  I  watch  every  step  of  the  sound  and 
every  corresponding  answer  of  the  uterus,  beyond  the  point  accessible  to 
the  eye,  the  external  os.  Every  obstacle,  every  deviation  in  the  direction 
of  the  uterine  canal  is  detected  and  gauged  by  two  practised  fingers,  and 
overcome,  and  injury  prevented  by  the  combined  action  of  two  hands. 
Through  the  speculum  the  point  of  the  sound  is  blindly  thrust  forward 
wherever  the  canal  allows  it  to  go,  and  valuable  information  imparted  by 
the  mobility  and  docility  of  the  uterus  under  the  domination  of  the  sound 
is  entirely  lost.  Introduced  thi'ough  the  speculum,  even  though  it  be  the 
Sims,  the  sound  shows  us  only  the  patency,  direction,  and  length  of  the 
uterine  canal ;  but  if  there  be  obstacles  to  its  progress,  such  as  ru- 
gosities of  the  cervical  mucous  membrane,  flexions  or  maljposition  of  the 
uterus,  the  instrument  will  generally  fail  to  pass  the  obstruction  unless 
forc3  be  used  or  the  tenaculum  eniployed  to  straighten  the  uterus.  Intro- 
duced on  the  finger,  however,  his  practised  touch  enables  the  expert,  with 
the  aid  of  the  internal  finger,  to  overcome  these  and  gently  and  safely  pass 
the  sound  to  the  fundus.  When  the  sound  is  counterindicated  the  probe 
comes  into  play,  and  it  should  be  passed  only  through  a  Sims  speculum. 
To  introduce  the  sound,  as  many  do,  through  a  tubular  or  bivalve  specu- 
lum is  unscientific  and  useless,  to  say  the  least. 

The  patient  occupies  the  dorsal  position,  the  physician  stands  before 
her  and,  having  made  the  ordinary  digital  and  bimanual  examination,  and 
found  an  indication,  and  no  counterindication  for  the  sound,  grasps  the 
handle  of  the  instrument  between  the  tips  of  the  thumb  and  first  two 
fingers  (like  a  penholder),  and  gently  insinuates  its  point  between  the  labia. 
In  removing  the  sound  from  the  basin  of  warm  water,  and  anointing  it, 
all  clatter  and  display  of  tha  instrument  should  be  avoided,  as  likely  to 
alarm  and  annoy  the  patient.  It  is  best  not  to  refer  to  the  intention  of 
sounding  at  all,  but  to  quietly  introduce  it  under  the  sheet  and  merely 
make  a  soothing  remark  when  the  passage  of  the  internal  os  or  the  touch- 
ing of  the  fundus  gives  pain. 

The  examining  finger,  with  its  volar  surface  upward,  rests  against  the 
lower  lip  of  the  cervix  ;  the  sound,  with  its  convexity  downward,  is  passed 
along  the  finger  until  it  reaches  the  cervix,  and  the  point  is  then  gently 
insinuated  into  the  os,  and  up  the  cervical  canal  until  the  region  of  the 
internal  os  is  reached,  that  is,  about  one  inch.  As  soon  as  the  tip  of  the 
sound  is  engaged  in  the  cervical  canal,  the  middle  finger  is  withdrawn  from 
the  handle,  and  the  thumb  and  forefinger  alone  manage  it  with  the  utmost 
delicacy,  scarcely  more  than  touching  the  handle.  If  the  uterus  occupies 
the  usual  position  of  antecurvature,  the  sound  will  generally  meet  with  a 
very  slight  impediment  at  the  internal  os^  which  is  recognized  by  the  ex- 
pert, and  immediately  overcome  by  gently  depressing  the  handle,  when  the 
tip  will  slip  over  the  ring  of  the  internal  os  and  glide  at  once  to  the  fundus. 
When  the  moment  arrives  to  depress  the  handle  in  passing  the  internal  os, 
it  is  convenient  to  change  the  position  of  the  fingers,  placing  the  tijp  of  the 


INDICATIONS    AND    PRECAUTIONS    FOR    USE    OF    SOUND.      105 

tliumb  on  the  handle,  the  index-finger  below  it.  The  sensation  imparted 
to  the  finger  of  the  examiner,  when  the  sound  touches  the  fundus,  is  that 
of  a  soft,  semi-elastic  resistance  ;  the  sensation  experienced  by  the  patient 
is  that  of  a  more  or  less  acute  pain  near  the  umbilicus,  but  this  onl}'  when 
the  sound  actually  presses  against  the  fundal  mucous  membrane.  That 
the  greatest  delicacy  is  imperative  in  passing  the  sound  through  the  inter- 
nal OS,  is  apparent,  when  we  consider  that  the  distance  from  that  point  to 
the  fundus  is  only  1^",  and  that  the  sudden  forcible  passage  of  the  appar- 
ent obstruction  might  result  in  the  tip  being  driven  sharply  against  the 


Fig.  66. — Position  of  Hands  in  Introducing  the  Sound  into  the  External  Os,  and  Change  of  Position  as  the 
Sound  slips  through  the  Internal  Os  (P.  P.  M. ). 


sensitive  fundus,  and  perhaps  through  it.  In  fact,  the  less  the  fundus  is 
irritated  by  the  sound  after  it  has  once  been  touched  the  better.  The 
fundus  thus  reached,  and  the  patency  of  the  uterine  canal,  and  the  tender- 
ness of  the  internal  os  and  fundus  noted,  the  internal  finger,  which  all  this 
time  has  retained  its  position  against  the  cervix,  is  pressed  firmly  against 
the  sound  at  the  spot  where  it  issues  from  the  os,  and  the  sound  is  with- 
drawn with  the  finger  in  that  position  ;  the  point  thus  marked  on  the 
sound  Avill  indicate  the  length  of  the  uterine  cavity.  In  a  normal  uterus 
the  finger  will  be  arrested  at  the  small  knob  with  which  every  Simpson 
sound  is  provided  at  a  distance  of  2V'  from  the  tip.  The  approach  of  this 
knob  should  indeed  be  used  as  an  alarm  to  the  internal  finger  that  the 


106 


GYNECOLOGICAL    EXAMINATION". 


tip  of  the  sound  is  near,  or  at  the  fundus.     The  character  of  the  secretion 
attached  to  the  sound  and  finger,  if  any,  should  be  noted. 

When  the  uterus  occupies  the  normal  position,  and  the  external  and 
internal  os  and  whole  uterine  canal  are  widely  patent,  and  the  latter 
devoid  of  entangling  ragosities,  the  passage  of  the  sound   is   an    easy 


Fig.  67. — Manner  of  Introducing  the  Sound  in  Anteflexion  (P.  F.  M.). 

matter,  even  to  the  beginner.  But,  when  the  cervix  is  turned  far  back,  or 
curled  up  anteriorly,  when  the  external  os  is  scarcely  perceptible,  or  there 
is  a  sharp  flexion,  particularly  anteflexion,  of  the  body  of  the  uterus,  even 
the  expert  may  fail  at  the  first  attempt.  In  a  very  small,  or  soft,  or  conical 
cervix,  the  external  os  may  be  hardly  larger  than  a  pin's  head  at  the  very 
apex  of  the  cone,  often  with  velvety  lips,  and  therefore  hard  to  detect  and 
locate.  Occasionally  the  speculum  is  required.  If  indagation  has  shown 
the  uterus  to  be  retrodisplaced,  the  sound  will  be  introduced  about  up  to 
the  internal  os,  in  the  usual  manner,  and  then  gently  rotated,  and  the 
handle  raised  instead  of  being  depressed,  as  in  antedisplacement ;  the 


Pig.  6S.— Manner  of  Introducing  the  Sound  in  Retroversion  (P.  F.  M. ). 

point  then  glides  over  the  internal  os,  and  backward  to  the  fundus,  the 
concavity  of  the  instrument  looking  backward.  If  there  is  an  ante-  or 
retroflexion,  the  uterine  portion  of  the  sound  should  be  bent  to  correspond 
to  the  probable  curve  of  the  canal.  This  is  chiefly  necessary  in  anteflexion. 
Occasionally,  however,  cases  are  met  with  in  which  even  the  most  acute 


INDICATIONS    AND    PRECAUTIONS    FOR    USE    OF    SOUND.      107 

angle  of  flexion  yields  to  the  normal  slight  curvature  of  the  sound  ;  this 
occurs  when  the  flexion  is  recent,  or  the  uterine  tissue  is  very  flaccid  or 
atrophic.  Thus  I  recently  saw  such  a  case  in  a  young  lady  twenty-two 
years  of  age,  whose  flexion  was  probably  due  to  forced  exercise  while  at 
boarding-school.  Her  uterus  was  flexed  in  the  third  degree,  cervix  and 
fundus  touching  ;  but  the  sound  passed  straight  to  the  fundus,  encounter- 
ing almost  no  obstacle  at  the  angle.  As  soon  as  it  was  withdrawn,  the 
uterus  returned  to  its  flexion.  A  valuable  hint  for  treatment  was  thus 
given,  viz.  :  the  uselessness  of  attempting  to  straighten  so  flabby  a  uterus  by 
vaginal  supports;  a  stem,  probably  a  galvanic  stem,  was  needed  to  straighten 
and  stimulate  the  uterus  to  retain  its  erect  shape.  This  feeling  of  relaxa- 
tion of  the  uterus  could  never  have  been  imparted  by  the  sound  alone 
through  a  speculum  ;  the  internal  finger  was  needed  to  control  the  sensation. 

It  not  unfrequently  happens  in  apparently  normal  cases  that  the  point 
of  the  sound  is  arrested  in  the  cervical  canal,  or  at  the  internal  os  ;  the 
point  is  then  probably  caught  in  some  fold  or  pocket  of  the  mucous  mem- 
brane, and  a  little  gentle,  lateral,  and  perpendicular  pendulum  or  rotary 
movement  of  the  handle  generally  soon  overcomes  the  obstacle.  In  some 
instances  of  anteflexion,  I  have  found  the  uterus  so  movable  that  the  mere 
pressure  of  the  tip  of  the  sound  at  the  internal  os  would  push  the  cer\dx 
so  far  back  as  to  prevent  the  sound  from  entering  the  cavity  of  the  uterus ; 
the  internal  finger  may  then  draw  the  cervix  forward  and  thus  straighten 
the  uterus,  or  it  may  go  in  front  of  the  cervix  and  push  the  body  back, 
or  the  sound  is  grasped  between  the  thumb  and  forefinger  of  the  examin- 
ing hand,  and  held  in  situ,  while  the  external  hand  leaves  the  handle  of 
the  sound  and  through  the  abdominal  wall  presses  the  fundus  back  and,  as 
it  were,  pushes  the  uterus  down  over  the  sound.  Of  course  this  must  be 
done  very  gently. 

I  have  found  beginners  to  fail  most  frequently  in  passing  the  internal 
OS,  because  they  neglected  to  depress  the  handle  sufficiently,  or  did  so  too 
soon  before  the  tip  had  reached  the  internal  os.  In  the  former  cases  tim- 
idity was  generally  at  fault,  and  after  several  ineffectual  attempts,  they 
would  give  it  up.  Nothing  but  practice  can  teach  the  beginner  to  appre- 
ciate and  overcome  these  difficulties  ;  they  can  merely  be  described  on 
paper,  their  recognition  must  be  learned  by  experience. 

Some  authors  (chiefly  English),  recommend  the  introduction  of  the 
sound  by  the  touch  in  the  lateral  position.  It  can  be  done,  of  course  ;  but 
I  fail  to  see  the  utility  of  substituting  an  inconvenient,  and  in  no  way  pref- 
erable method,  to  one  in  every  way  suitable.  The  sound  may  also  be  used 
through  thejj»  speculum  (Sims',  of  course),  and  the  length,  wddth,  and 
course  of  the  canal  thus  ascertained.  It  will  do  as  well  as  the  probe  in  all 
cases  where  a  flexible  instrument  is  not  preferable.  To  ascertain  the 
width  of  the  canal,  Peaslee's  thick  sound  is  advisable.  While  I  am  per- 
fectly familiar  with  the  manner  and  also  the  advantages  of  introducing  the 
sound  through  Sims'  speculum,  I  still  prefer  to  insert  it  ordinarily  hy  the 
touch  alone,  for  reasons  sufficiently  stated  above.  In  pi'actical  matters  of 
this  kind  each  man  must  be  his  own  authority. 


108  GYNECOLOGICAL    EXAMINATION. 

The  x^'^'obe  is  Introduced  only  througli  a  speculum,  always  preferably 
the  Sims.  Its  flexibility  only  allows  it  to  follow  the  direction  of  the 
uterine  canal ;  if  the  latter  is  particularly  tortuous,  the  probe  requires  to 
be  bent  in  various  curves,  according  to  the  previous  examination,  until 
the  correct  one  is  finally  found  and  the  tip  passes  the  obstruction.  This 
curve,  being  retained  on  its  withdrawal,  gives  the  course  of  the  uterine 
canal,  a  valuable  piece  of  information.  The  paramount  advantage  of  the 
probe  over  the  sound  is  its  safety,  the  slight  irritation  it  produces,  the 
absence  of  all  force.  Its  disadvantages  are  the  limited  information  it  im- 
parts, the  ease  with  which  its  flexible  or  elastic  tip  is  caught  in  a  fold  of 
the  cervical  mucous  membrane,  and  its  progress  impeded  or  prevented, 
and  the  necessity  of  using  a  speculum  through  which  to  introduce  it. 

It  is  not  necessary  to  describe  the  manner  of  passing  the  probe  through 
a  cylindrical  or  bivalve  speculum,  because  the  maneuvre  is  exceedingly 
simple  and — because  it  frequently  fails.  Through  the  Sims  speculum  the 
method  is  as  follows :  The  cervix,  being  exposed,  is  seized  by  the  tenacu- 
lum and  gently  drawn  down,  thereby  straightening  the  uterus  ;  the  left 
hand  then  taking  the  tenaculum,  the  right  gently  slips  the  probe  into  the 
uterus,  having  given  it  the  curve  which  a  previous  examination  has  indi- 
cated. "When  the  probe  has  reached  the  fundus,  the  right  index  is  j^assed 
into  the  vagina,  or  the  dressing  forceps  grasps  the  probe  at  the  external 
OS,  and  thus  marks  the  length  of  the  uterine  canal,  which  must  be  meas- 
ured by  tape-measure,  since  the  probes  are  not  graduated. 

The  special  indications  for  the  use  of  the  probe  are  either  extreme  nar- 
rowness or  tortuosity  of  the  uterine  canal,  or  the  necessity  for  exceed- 
ing gentleness  for  fear  of  re-exciting  inflammatory  processes,  which  even 
the  probe  may  occasionally  do. 

The  elastic  probes  of  hard  rubber  or  whalebone  are  used  in  very  tor- 
tuous canals  on  account  of  their  slenderness  and  weakness.  Thomas'  flat 
whalebone  sound  has  already  been  described. 


D.  Dilatation  of  the  Uterus  for  Purposes  of  Diagnosis  (Inspection  and  Inda- 
gation  of  the  Dilated  Uter^us). 

It  frequently  becomes  necessary,  in  order  to  settle  a  diagnosis,  that  a 
view  of  the  endometrium  be  obtained,  or,  what  is  vastly  more  useful,  that 
the  finger  be  passed  into  the  uterine  cavity.  In  order  to  do  this,  the  nar- 
row uterine  canal,  ordinarily  passable  only  for  a  sound,  must  be  dilated 
to  the  width  of  at  least  an  inch.  This  may  be  done  by  rapid  forcible  dila- 
tation by  means  of  powerful  two-  or  three-branched  diverging  steel  dilators, 
or  by  a  gradual  and  slow  dilatation  with  compressed  cones  of  sponge 
(sponge-tents),  swelling  bougies  of  laminaria  or  tupelo  ;  or  again,  by  rubber 
tubes  into  which  water  is  forced  from  a  syringe  until  they  have  acquired 
the  desired  size.  As  all  these  manipulations  require  a  certain  amount  of 
preparation,  and  are  also  used  for  therapeutical  purposes,  I  will  defer  their 
description  to  the  next  chapter,  and  will  only  describe  here  the  conditions 


DILATATION    OF    UTERUS    FOE    PURPOSES    OF    DIAGNOSIS.      109 

calling  for  inspection  and  indagation  of  the  uterine  ca^dty,  and  tLe  results 
of  such  examination. 

The  information  imparted  by  insj)ection  of  the  cervical  and  uterine  cavi- 
ties, particularly  of  the  latter,  is  exceedingly  meagre.  If  the  cervix  is 
largely  dilated,  as  immediately  after  abortion,  childbirth,  or  the  removal  of 
a  s]3onge-tent,  or  if  it  is  lacerated,  its  "walls  may  be  separated  by  a  steel  di- 
lator and  a  view  of  its  cavity  obtained  through  a  Sims  speculum  almost  up 
to  the  OS  internum  ;  or  the  lips  may  be  separated  by  forcing  a  tubular  or 
bivalve  speculum  well  up  into  the  cul-de-sac.  Useful  information  as  to  the 
color  of  the  endocervical  mucous  membrane,  especially  as  to  the  presence 
of  hyperjDlastic  follicles,  may  be  thus  obtained.  To  obtain  a  view  of  the 
upper  portion  of  the  cervical  and  any  part  of  the  iiterine  cavity  proper,  an 
instrument  is  required  similar  to  that  devised  by  Dr.  Skene  for  the  bladder. 
If  the  internal  os  is  sufficiently  dilated  to  admit  one  of  the  sizes  of  this 
endoscope,  a  view  of  the  uterine  mucosa,  exactly  jDroportionate  to  the 
diameter  of  the  tube  employed,  will  be  obtained.  By  means  of  reflected 
(artificial)  light  this  small  disk  may  be  clearly  exposed.  But,  compared 
with  the  information  imparted  to  that  real  eye  of  the  gynecologist,  the  tip 
of  his  index-finger,  this  glimpse  of  the  endometrium  possesses  but  little 
value.  With  the  cervix  once  dilated  sufficiently  to  admit  the  endoscope, 
it  will  be  found  vastly  more  useful  to  pass  the  finger  into  the  uterine  ca\ity 
and  touch  its  whole  surface,  than  to  see  one  small  disk  one-half  to  one  inch 
in  diameter.  For  it  must  be  remembered  that  the  tube  cannot  be  shifted 
and  pointed  in  different  directions,  as  in  the  large  sac  of  the  bladder. 

Passing  the  point  of  the  index-finger  into  the  cervical  canal,  and  crowding 
down  the  fundus  with  the  external  hand,  or  drawing  down  the  uterus  with 
a  double  tenaculum  inserted  into  the  cervix,  the  finger  first  feels  the  endo- 
trachelian  mucosa,  its  roughness  or  smoothness,  chiefly  the  condition  of 
the  follicles.  If  these  are  enlarged  and  the  mucosa  is  unusually  rugous,  the 
endotrachelitis  and  the  stringy  discharge,  which  then  doubtless  exist,  will 
not  be  cui'able  by  caustics  or  mild  applications,  but  requu'e  the  removal 
of  the  hyperplastic  tissue  by  the  shai-p  curette.  Other  pathological  con- 
ditions, except,  perhaps,  a  mucous  or  fibrous  polypus,  or  a  sacculated 
enlargement  of  the  cervical  canal,  are  not  met  with  between  the  external 
and  internal  os.  A  malignant  degeneration  of  the  cervix  can  always  be 
detected  by  the  external  touch  of  that  part,  and  submucous  fibroids  in  the 
tissue  of  the  cervix  alone  and  growing  only  toward  that  cavity  are  very 
rare.  Disease  of  the  mucous  membrane  or  muscular  tissue  of  the  body 
of  the  uterus,  is  frequently  met  with  and  often  recognizable  only  by  the 
finger  in  the  uterine  cavity.  It  is  true  that  by  the  aid  of  the  curette  and 
whalebone  probes  degeneration  of  the  mucosa  and  submucous  tumors  may 
usually  be  recognized,  but  a  positive  diagnosis  or  confirmation  can  at  times 
be  obtained  only  by  the  finger.  The  pathological  conditions  thus  calling 
for  uterine  indagation  are,  benign  or  malignant  degeneration  of  the  mucosa 
(hyperplastic  pulpy  condition  of  membrane,  vegetations  ;  diffuse  or  cu-- 
cumscribed  sarcoma),  submucous  or  interstitial  fibroids  and  polypi,  and 
retained  portions  of  membranes  or  placenta  (generally  after  miscarriage). 


110  GYNECOLOGICAL    EXAMINATION". 

The  removal  of  small  portions  of  the  mucous  membrane  or  pathological 
growth  (sarcoma,  or  placenta)  and  their  examination  under  the  microscope 
will  generally  clear  the  diagnosis  without  doubt ;  but  in  fibroids  indaga- 
tion  ia  often  the  only  means  of  ascertaining  the  presence,  size,  and  attach- 
ment of  the  tumor.  Thus,  in  differentiating  between  inversion  of  the 
uterus,  and  a  fibroid  polypus  with  thick  pedicle,  the  finger  alone  can 
decide  from  which  side  the  polypus  springs,  if  it  proves  not  to  be  an 
inversion. 

E.    Examination  of  the  Uterus  with  the  Curette  for  Diagnostic  Purposes. 

In  disease  of  the  endometrium  it  is  often  impossible  to  make  a  diagnosis 
without  a  macro-  or  microscopical  examination  of  the  affected  tissue.  I 
have  already  shown  that  an  ocular  inspection  of  the  uterine  cavity  is  limited 
and  unsatisfactory  ;  the  only  other  means  at  our  disposal  are,  therefore,  to 
bring  the  diseased  tissue,  or  a  portion  of  it,  where  we  can  examine  it  at 
our  leisure.  This  is  done  by  introducing  a  spoon-shaped  instrument 
with  cutting  or  dull  edges  and  removing  a  small  portion  of  the  mucous' 
membrane  or  tumor  ;  the  character  of  the  disease  may  be  apparent  at  a 
glance,  as  in  the  common  polypoid  vegetations  and  granulations,  and  the 
diffuse  pulpy  hyperplasia  of  the  mucous  membrane  ;  or  other  symptoms 
may  call  for  microscopical  examination,  as  in  sarcoma.  The  curettes  first 
devised  and  employed  had  semi-acate  or  cutting  edges  ;  Recamier's  and 
Sims'  curettes  are  representatives  of  this  class. 

The  shai-p  edges,  while  invaluable  where  it  is  desired  to  cut  deeply 
and  remove  all  the  diseased  tissue,  are  obviously  dangerous  and  certainly 
unnecessary  when  only  a  superficial  shaving  or  a  small  particle  is  to  be 
removed  for  purposes  of  diagnosis.  The  later  instrument  of  Thomas  is 
therefore  greatly  to  be  preferred  to  the  sharp  curettes,  and  answers  every 
purpose.  It  is  made  of  flexible  copper  wire,  the  loop  being  flattened  on 
one  surface  so  as  to  give  it  a  dull  edge,  and  the  thinness  of  the  wire  at 
the  neck  of  the  loop  and  close  to  the  handle  renders  the  instrument  almost 
incapable  of  sufficient  impression  to  do  injury.  The  loop  in  the  smallest 
size  made  is  one-sixth  of  an  inch  broad,  but  a  loop  of  one-fourth  inch  is 
the  size  usually  employed.  The  instrument  is  nine  inches  long,  three 
inches  and  a  half  of  which  form  the  wooden  handle,  which  is  roughened 
on  the  surface  corresponding  to  the  scraping  surface  of  the  loop  ;  the  wire 
is  one-sixth  of  an  inch  thick  near  the  handle,  and  tapers  down  from  one- 
twelfth  to  one-sixteenth  of  an  inch  thick  at  the  inception  of  the  loop. 
(See  chapter  on  Therapeutic  Curetting.) 

Indications. — The  one  indication  for  the  blunt  curette  as  a  means  of 
diagnosis  (I  entirely  omit  the  sharp  curettes  for  this  purpose)  is  the 
existence  of  pathological  hemorrhage  from  the  cavity  of  the  uterus — men- 
orrhagia  or  metrorrhagia — for  which  no  adequate  cause,  constitutional  or 
local,  can  be  detected  by  the  ordinary  methods  of  exploration,  and  which 
has  resisted  the  usual  remedies.  Experience  has  shown  us  that  such 
uterine  hemorrhage  is  very  often  due  to  the  irritation  produced  by  small 


EXAMIN^ATION    OF    UTERUS    WITH    THE    CURETTE.  Ill 

wart-like  or  polypoid  growths  in  the  uterine  cavity,  or  to  a  pul2:)y,  liypei'- 
plastic,  and  hyperemic  friable  condition  of  the  mucous  membrane,  or  to  a 
granular  condition  of  its  surface,  similar  to  that  of  a  varicose  ulcer  ;  or, 
finally,  to  the  retention  of  often  very  minute  fragments  of  adherent  pla- 
centa after  miscarriage.  Diffuse  sarcoma  of  the  mucous  membrane  is  a 
rare  affection,  but  as  fatal  as  it  is  rare.  Again,  true  cancerous  degenera- 
tion of  the  mucous  membrane  of  the  cavity  of  the  uterus  proper  occa- 
sionally occurs.  In  sarcoma  and  carcinoma  of  the  body  of  the  uterus  the 
pelvic  pains  and  cachexia  will  give  some  suspicion  of  the  true  nature  of 
the  case  ;  but  the  hemorrhage,  after  all,  is  the  main  symptom,  and  the 
positive  diagnosis  can  be  made  only  by  a  microscopical  examination  of  the 
diseased  mass. 

In  all  these  cases  the  curette  is  indicated  and  will  rarely  fail.  The 
withdrawal  of  small  jelly-like  bodies  of  a  pale  pink  translucent  color,  and 
of  the  size  of  a  canary-seed,  or  slightly  larger,  shows  the  presence  of  the 
condition  known  as  endometritis  polyposa.  If  thin  slices  of  a  pulpy  tissue 
are  removed,  we  have  endrometritis  hyperplastica  ;  if  merely  stringy  mucus, 
mixed  with  blood  and  shreds,  comes  away  with  the  curette,  we  have  endo- 
metritis granulosa  or  hemorrhagica  ;  if  small,  firm  masses  of  the  size  of  a 
pea  or  bean  are  removed,  the  hemorrhage  was  due  to  retention  of  adherent 
placental  villi ;  if,  finally,  friable,  spongy,  parti-colored  masses  are  removed, 
especially  if  abundant,  and  perhaps  offensive,  the  probability  of  malignant 
disease  is  great.  Of  course,  such  brief  and  general  characteristics  as  I  have 
here  given  cannot  be  considered  pathognostic  ;  the  microscope  can  alone 
make  the  positive  diagnosis,  and  I  should  advise  that  its  decision  be  invoked 
in  every  case  coming  under  this  category  before  pronouncing  either  a  diag- 
nosis or  a  prognosis. 

The  peculiar  sensation  imparted  to  the  finger  on  drawing  the  curette 
over  the  endometrium  may  give  some  hint  as  to  the  nature  of  the  affection  : 
if  it  is  a  grating,  vegetations  or  placental  fragments  ;  if  soft  or  spongy,  one 
of  the  other  conditions. 

Counterindications  are  all  conditions  which  would  prohibit  any  interfe- 
rence with  the  endometrium,  even  sounding  or  probing,  in  fact  all  present 
or  recent  inflammatory  trouble  in  or  about  the  uterus. 

Operation. — The  smallest  size  of  blunt  curette  (one-sixth  inch  loop)  can 
generally  be  passed  through  every  uterine  canal,  at  least  in  women  who  have 
had  a  bloody  or  mucous  discharge  from  the  uterus  for  some  time  ;  for  such 
a  flow  generally  relaxes  and  dilates  the  canal.  In  case  an  obstacle  is  met 
with,  and  that  will  generally  be  at  the  internal  os,  the  canal  should  be 
gently  dilated  with  a  steel  or  graduated  dilator,  or,  in  case  of  excessive 
rigidity,  laminaria  or  sponge-tents  may  be  required.  For  ordinary  diag- 
nostic curetting  I  do  not  remember  ever  needing  more  than  rapid  dilatation 
with  a  two-branched  instrument  to  render  the  canal  passable. 

The  curette  may  be  introduced  simply  by  the  touch,  but  the  removal 
and  preservation  of  the  products  of  the  sci'aping  would  then  be  difficult. 
It  is  therefore  always  advisable  to  practice  the  curetting  tlu'ough  a  specu- 
lum, and  then  always  a  large  bivalve  or  the  Sims.     A  very  large,  tubular 


112  GYNECOLOGICAL  EXAMINATION. 

speculum  might  possibly  do,  but  the  curette  is  really  too  short  to  be  prop- 
erly handled  in  that  way.  A  bivalve  is  better,  and  will  answer  for  many 
cases  ;  but  I,  it  need  hardly  be  said,  prefer  the  Sims  in  this,  as  in  every 
measure,  requiring  a  speculum.  I  shall,  therefore,  describe  the  operation 
through  the  latter  instrument,  since  through  the  tubular  and  bivalve  sjaec- 
ula  it  consists  merely  in  thrusting  the  properly  bent  curette  up  to  the 
fundus,  and  withdrawing  it  with  whatever  comes  with  it.  I  must,  how- 
ever, admit  that,  in  the  absence  of  assistance,  a  bivalve  will  do  for  diagnos- 
tic curetting  ;  for  the  therapeutical  use  of  the  scoop  I  should  not  recom- 
mend it. 

The  cervix  being  exposed  through  Sims'  speculum,  the  anterior  lip  is 
seized  with  a  tenaculum,  and  the  uterus  gently  drawn  down  so  as  to 
straighten  it ;  the  probe  or  sound  is  passed  to  the  fundus,  and  the  direc- 
tion and  length  of  the  canal  and  curve  of  the  sound  noted.  I  prefer  the 
sound  for  this  exploration,  as  it  gives  me  a  better  idea  of  the  width  of  the 
canal.  The  curette  is  then  bent  in  the  curve  indicated  by  the  sounding, 
seized  between  the  thumb  and  two  fingers  of  the  right  hand,  and  gently 
passed  through  the  cervical  canal  and  internal  os.  Arrived  at  the  fundus, 
the  curette  is  drawn  gently  (with  thumb  and  index-finger)  downward  to- 
ward the  internal  os,  taking  successively  the  anterior,  two  lateral,  and  pos- 
terior surfaces  of  the  uterus.  The  direction  of  the  flattened,  scraping  sur- 
face is  recognized  by  the  corresponding  roughness  on  the  handle  ;  of 
course  the  curette  is  bent  so  as  to  bring  the  scraping  surface  to  correspond 
with  the  concavity  of  the  shank.  The  four  surfaces  having  been  gently 
scraped,  note  being  taken  of  the  sensation  thereby  imparted  to  the  fingers, 
the  curette  is  withdrawn.  With  it  there  will  generally  be  a  slight  oozing, 
in  the  midst  of  which  Avill  be  found  the  results  of  the  scraping,  if  there  be 
any.  The  blood  is  wiped  up  with  a  bit  of  cotton-batting  on  the  uterine 
dressing  forceps,  and  carefully  examined.  If  any  of  the  substances  above 
described  have  been  removed,  they  will  easily  be  recognized  on  the  cotton 
by  their  characteristic  appearance,  and  can  be  overlooked  or  mistaken  for 
blood  only  through  carelessness  or  ignorance.  If  nothing  whatever  but 
clear  semi-coagulated  or  fluid  blood  and  mucus  appears  on  the  cotton  at 
first,  the  vagina  should  be  again  wiped  out  with  fresh  cotton,  and  perhaps 
a  cotton- wrapped  applicator  may  be  j)assed  to  the  fundus,  on  which  the 
debris  may  be  withdrawn.  Occasionally  the  exploration  is  entii-ely  nega- 
tive, and  then  a  point  in  the  diagnosis  is  gained  by  elimination  of  intra- 
uterine disease, 

A  diagnostic  curetting,  done  gently  and  lege  artis,  can  be  performed 
with  as  little  risk  as  the  introduction  of  the  sound,  and  the  patient  be  al- 
lowed to  go  about  her  usual  duties  soon  afterward.  The  precaution  of  rest 
and  care  for  several  hours,  of  course,  applies  to  this  maneuvre  even  more 
than  to  the  sound. 

I  have  employed  the  curette  in  this  way  many  times,  and  have  never 
seen  any  other  reaction  than  a  slight,  bloody  oozing  for  a  day  or  two. 
I  always  do  it  in  my  ofiice  or  the  out-door  clinic.  Any  extra  caution  in 
the  way  of  keeping   the  patient    in   bed   or  on  the  lounge  for  the  rest 


AKTIFICIAL    PROLAPSUS    OF    THE    UTERUS. 


113 


of  the  day  can  but  be  commended,  if  the  medical  attendant  or  the  pa- 
tient see  fit. 


F.  Artificial  Prolapsus  of  the  Uterus  for  Diagnostic  Purposes. 

It  has  already  been  mentioned  that  the  uterus  can  be  seized  by  the 
single  tenaculum  and  slightly  drawn  down  and  straightened,  during  an 
examination  with  the  Sims  speculum.  A  gentle  traction  of  this  kind  re- 
quires but  very  little  force,  and  can  do  no  harm  ;  its  object  really  is 
more  to  steady  the  cervix  and  bring  it  in  the  line  of  vision  than  to  draw  it 
down. 

But  cases  are  not  uncommonly  met  with  in  which  it  is  desirable  or 
necessary  to  dislocate  the  uterus  downward  to  its  utmost  hmit  for  pur- 
poses of  diagnosis  or  treatment.  Such  cases  are  those  in  which  the 
finger  is  to  be  passed  into  the  uterine  cavity ;  or  into  the  rectum  or 
bladder,  or  both,  in  order  to  make  the  diagnosis  of  retro-  or  ante-uterine 
growths,  or  differentiate  between  inversion  of  the  uterus  and  fibroid  poly- 
pus, by  reaching  the  infundibulum  of  .the  inverted  organ.  For  thera- 
peutical purposes  the  artificial  prolapsus  is  practised  during  the  removal  of 
intra-uterine  growths  (fibroids,  polypi),  during  the  operation  for  laceration 
of  the  cervix  uteri,  amputation  of  the  cervix,  and  extirpation  of  the  entire 
uterus  per  vaginam. 


Fig.  69. — Noeggerath's  Vulsella-forceps  for  Dislocating  Uterus  Downward  ;  also  with  Sound  attached  for 

Lateral  Dislocation. 


The  cervix  of  the  normally  movable  uterus  may  be  drawn  down  to  the 
vulva  by  seizing  it  with  a  double  tenaculum  or  a  double-pronged  hook. 
Or  the  more  powerful  vulsella  may  be  used.  If  Hanks'  double  tenaculum 
is  used,  the  cervix  may  be  seized  either  by  one  lip,  or  both  lips  are  grasped 
from  within  ;  with  Noeggerath's  instrument  the  grasp  must  be  from  with- 
in. The  hooks  may  be  fixed  either  by  the  touch  or  through  the  Sims  or 
Simon  speculum  (the  only  available  specula  for  this  maneuvre).  If  the 
prolapsus  is  to  facilitate  indagation,  a  speculum  is  not  necessary.  If  for 
operation,  the  Sims  or  Simon  is  indicated.  Occasionally  indagation  may 
be  practised  on  the  uterus  when  it  is  drawn  down  in  the  speculum.  When 
the  traction  ceases,  the  uterus  rapidly  returns  to  its  site.  A  supposed  in- 
verted uterus  is  best  drawn  down  by  passing  a  broad  tape  about  the  pedi- 
cle and  using  it  as  a  means  of  traction.  A  wire  or  thread  loop  may  also 
8 


114  GYNECOLOGICAL    EXAMINATION. 

be  passed  througli  one  or  the  other  Hps  of  the  cervix  and  used  as  a  tractile 
force. 

Counterindications  to  this  practice  are  fresh  or  chronic  inflammatory 
deposits  about  the  uterus  ;  the  latter,  indeed,  may  fix  the  organ  so  firmly 
as  to  render  its  protraction  impossible,  while  the  former  make  it  exceed- 
ingly dangerous.  Occasionally  an  inflammatory  reaction  follows  the  arti- 
ficial prolaj)se  of  even  the  normally  mobile  uterus.  Quite  recently  Her- 
mann, in  Mannheim,  Germany,  reported  a  case  in  which  rupture  of  an 
adherent  inflamed  and  dilated  Fallopian  tube,  with  subsequent  fatal  peri- 
tonitis, occurred  after  the  ordinary  diagnostic  prolapsus  of  the  apparently 
perfectly  mobile  uterus.  Of  coiu'se,  the  presence  of  the  serous  salpingitis 
and  the  adhesions  had  not  been  susjoected.  Schroder  pointed  out,  several 
years  ago,  the  danger  of  accidentally  tearing  a  pyo-salpinx  during  this 
maneuvre,  but  added  that  in  more  than  two  hundred  instances  of  arti- 
ficial prolapsus  he  had  never  witnessed  any  other  reaction  than  a  slight  ex- 
acerbation of  already  existing  perimetric  exudation.  It  is  evident  that 
this  method  should  never  be  employed  needlessly,  and  only  when  the  ex- 
amination or  operation  cannot  be  as  well  performed  Avith  the  uterus  in 
situ. 

In  this  connection  it  will  not  be  amiss  to  refer  to  the  injuries  which 
may  be  inflicted  on  the  cervix  by  the  single  or  double  tenaculum.  One  of 
the  objections  advanced  against  the  Sims  speculum  by  those  conservative 
gynecologists  who  have  never  really  acquu'ed  the  knowledge  how  to  use 
it,  is  the  wounding  and  laceration  of  the  cervix  by  the  tenaculum  requii-ed 
to  attract  and  steady  the  uterus  ;  such  lacerations,  they  claim,  besides  be- 
ing a  needless  disfigurement,  open  the  channel  to  septic  infection,  and  may 
be  followed  by  severe  hemorrhage.  It  is  true,  the  cervix  is  occasionally 
quite  severely  torn  by  the  tenaculum,  but  this  accident  is  usually  more 
annoying  to  the  physician,  who  again  and  again  loses  his  hold  on  the  brit- 
tle and  friable  tissue  of  the  part,  than  injurious  to  the  patient.  In  the 
normal  cervix  the  tenaculum  (at  least  the  properly  curved  tenaculum 
shown  on  page  84)  rarely  tears  out  when  properly  implanted ;  and,  to  my 
knowledge,  no  injurious  results  whatever  have  ever  followed  this  simple 
puncture.  In  those  cases  in  which  the  hook  tears  out,  and  gashes  are 
made  in  the  cervix,  the  latter  is  generally  in  a  condition  of  so-called  "cys- 
tic hyperplasia,"  its  tissue  and  surface  interspersed  with  distended  mucous 
follicles,  the  friable  walls  of  which  afford  almost  no  resistance  to  traction 
by  the  hook.  Such  gashes  are  always  supei'ficial  and,  emptying  as  they 
do  the  distended  folhcles,  rather  do  good  than  harm,  accomplishing  what 
systematic  puncture  and  scarification  is  employed  for.  I  have  never  seen 
the  shghtest  ill-effects  follow  any  of  the  innumerable  tenaculum-punctures 
which  I  have  inflicted.  Occasionally,  an  ectatic  vein  may  be  pricked  by 
the  tenaculum,  and  quite  profuse  hemorrhage  occur,  but  this  is  instantly 
arrested  by  a  cotton  tampon,  steeped  in  an  alum  or  tannin  solution  if  neces- 
sary. 


EXAMIISTATION  OF    THE    EECTUM    WITH   THE    SPECULUM.       115 


G.  Examination  of  the  Rectum  vrith  the  Speculum. 

Various  bi-  and  trivalve  specula  for  the  rectum  are  for  sale  and  more 
or  less  used,  but  they  possess,  in  reality,  no  advantages  over  two  Sims, 
specula,  one  for  the  anterior,  and  one  for  the  posterior  wall ;  or  a  simple 
Ferguson  or  hard-rubber  cylindrical  vaginal  speculum  will  answer  admi- 
rably for  many  purposes.  The  principle  intended  in  Thebaud's  sphincter 
ani  dilator  is  precisely  identi- 
cal with  that  of  the  two  Sims 
above  mentioned. 

Indications.  — Whenever 
deep-seated  disease  of  the  rec- 
tum is  suspected,  and  the  dig- 
ital eversion  of  the  lower  two 
inches  of  the  gut  through  the 

vagina     does     not     reveal     the  Fig.  70.-Bivalve  Anal  Specnlum. 

trouble,  a  specular  examination 

is  called  for.  Such  deeper-seated  disease  may  be  a  stricture,  a  recto- 
vaginal fistula,  a  fistulous  opening  of  a  pelvic  abscess,  an  ulcer,  internal 
hemorrhoids,  or  a  catarrhal  inflammation  of  the  rectal  mucosa,  a  proctitis. 
One  or  the  other  of  these  affections  is  not  unfrequently  met  with  as  a  com- 
plication of  uterine  disease,  and  the  indication,  therefore,  frequently  arises 
for  a  rectal  examination  as  a  means  of  detecting  the  source  of  rectal  pains 
or  discharges.  Painful  defecation,  and  the  discharge  of  mucus  or  piu'u- 
lent  matter  from  the  rectum  perhaps  gives  the  most  frequent  incentive 
to  such  a  course. 

Operation. — As  even  the  digital  eversion  of  the  rectum  from  the  va- 
gina gives  some  pain,  chiefly  through  the  dilatation  of  the  sphincter  ani 
in  forcing  the  anterior  rectal  wall  through  it,  so  will  the  distention  of  the 
sphincter  by  a  speculum  be  exceedingly  jDainful,  and  require  the  adminis- 
tration of  an  anesthetic.  A  mere  preparatory  inspection  of  the  lower  half 
of  the  rectum  through  a  smallest  sized  tubular,  bivalve,  or  Sims  speculum 
can  thus  be  made  without  injuring  or  previously  dilating  the  sjihincter 
ani.  But  a  clear  view  of  the  canal  can  only  be  obtained  b}^  introducing  a 
large  instrument,  and  this  requires  a  painful  stretching  of  the  sjohincter, 
which  is  rarely  practicable  without  anesthesia. 

The  patient,  being  anesthetized,  is  placed  in  the  lateral  position  (I  pre- 
fer the  left  for  this,  as  for  almost  every  manipulation  in  the  lateral  decu- 
bitus) and  a  medium  cylindrical  speculum  forced  through  the  sphincter 
into  the  rectum.  If  the  i-esistance  of  the  sphincter  is  once  overcome,  the 
expanded  rectum  offers  no  obstacle  to  the  progress  of  the  tube  up  to  its 
hilt.  Should  the  sphincter  oppose  the  introduction  of  the  speculum,  it 
will  either  be  necessary  to  make  the  examination  with  a  dilating  sj)eculum 
or  with  two  small  Sims,  which  are  readily  passed  through  a  normally  con- 
tracted sphincter  ani  (one  anterior,  the  other  posterior)  ;  or,  if  the  view 
thus  obtained  is  not  sufficient,  the  forcible  hj^erdistention  of  the  sphincter 


116  GYNECOLOGICAL    EXAMINATIOTST. 

should  precede  the  examination,  provided  the  necessity  for  the  latter  calls  , 
for  so  severe  a  measure.  This  hyperdistention  of  the  sphincter  is  very 
rapidly  performed,  by  introducing  the  two  thumbs  up  to  the  root  into  the 
rectum,  placing  the  four  fingers  of  either  hand  on  each  natis,  and  steadily 
and  forcibly  separating  the  thumbs  until  they  are  arrested  by  the  tuber 
ischii  on  each  side.  The  anus  then  becomes  a  yawning  cavity  of  at  least 
three  inches  diameter,  and  the  red,  pouting  rectal  mucosa  bursts  into  view 
to  the  depth  of  three  or  four  inches.  The  external  and  internal  sphincter 
may  be  merely  stretched  and  temporarily  paralyzed,  or  their  fibres  are 
entirely  or  partly  torn  ;  the  mucous  border  of  the  anus  is  generally  nicked 
in  several  places,  and  there  may  be  slight  hemorrhage.  The  consequences 
of  the  operation  are  none  but  beneficial  when  it  is  employed  for  thera- 
peutical purposes  (as  for  the  cure  of  fissure  of  the  anus,  for  which  it  is  a 
specific)  and  innocuous  when  used  as  a  means  of  diagnosis  ;  the  incon- 
tinence following  it  rarely  lasts  longer  than  a  few  days.  The  field  of 
vision  opened  by  this  hyperdilatation  may  render  a  further  specular  exami- 
nation unnecessary  ;  but  generally  the  mucous  membrane  falls  forward  so 
as  to  obscure  the  unobstructed  view,  and  a  speculum  or  retractors  are  re- 
quired to  separate  the  walls. 

A  large-sized  cylinder  will  now  afford  a  good  view,  which  can  likewise 
be  obtained  through  two  Sima  specula,  one  retracting  the  posterior,  and 
the  other  the  anterior  wall  of  the  rectum.  To  view  successively  the  whole 
circumference  of  the  rectal  tube  without  obstruction  by  the  blade  of  a 
speculum,  a  cylinder  is  perhaps  preferable  to  the  two  Sims. 

It  should  be  noted  that  the  mucous  membrane  of  the  rectum  is  of  a 
bright  red  color,  not  pale  pink  like  the  vagina.  If  it  has  a  bluish  or  dark 
red  color,  however,  it  is  congested  or  inflamed,  and  in  need  of  treatment ; 
so,  also,  if  it  is  coated  with  thick,  stringy  mucus. 

Applications  of  fluid  medicinal  substances  may  be  made  either  through 
the  cylindrical  or  double  Sims  specula.  If  the  cylinder  is  used,  the  fluid 
may  be  poured  into  the  speculum  and  brought  in  contact  with  the  interior 
of  the  rectum  by  withdrawing  the  speculum  or  mopping  it  on  the  mucous 
membrane  with  a  sponge  on  a  holder,  or  cotton  on  a  whalebone  stick  ;  the 
latter  is  also  the  method  of  applying  fluid  agents  through  the  Sims. 
Powders  (iodoform,  bismuth,  etc.),  may  likewise  be  applied  in  this  way, 
or  by  insufllation.  Solid  substances,  such  as  the  stick  of  silver-nitrate  to 
distinct  spots,  as  ulcers  or  chancres,  are  best  applied  through  the  two 
Sims,  as,  indeed,  nitric  acid  on  a  stick  when  also  used  to  touch  ulcers.  If 
a  stricture  close  above  or  at  the  internal  sphincter  interferes  with  the  ex- 
amination, it  should  be  divided  or  dilated.  If  the  examination  is  repeated 
within  a  week  it  will  generally  be  found  easy  to  dilate  the  sphincter  with 
the  speculum,  without  the  forcible  overdistention  first  employed  ;  later, 
the  normal  contraction  of  the  muscle  will,  in  the  vast  majority  of  cases, 
have  returned. 

The  importance  of  inspection  and  local  treatment  of  the  rectum  has 
been  recognized  only  within  recent  years,  and  is  particularly  to  be  insisted 
on  in  the  female  sex,  in  whom  affections  above  the  internal  sphincter  are 


MENSURATION    OF   THE    ABDOMEN    AND    PELVIS.  117 

more  common  than  in  the  male  (such  as  catarrhal  inflammation,  stricture, 
■internal  hemorrhoids,  internal  pelvic  fistula)  and  either  simulate  or  are 
closely  connected  with  and  productive  of  uterine  disease. 

H.   Mensuration  of  the  Abdomen  and  Pelvis. 

The  measurement  of  the  female  pelvis  is  ordinarily  useful  only  during 
pregnancy  as  a  prognostic  sign  of  impending  labor.  But  during  the  non- 
puerperal condition  it  may,  at  times,  be  valuable  in  cases  of  large,  fibroid 
tumors  of  the  uterus,  w^hen  the  question  of  removal  of  the  growth  per 
vaginam  is  under  discussion.  A  growth  of  moderate  size  may  be  removed 
entire,  but  in  a  contracted  pelvis  its  previous  segmentation  would  probably 
be  necessary. 

The  mensuration  of  the  abdomen,  on  the  other  hand,  is  of  decided 
importance  in  gynecology.  It  is  chiefly  useful  in  determining  the  dimen- 
sions of  that  cavity  in  uterine  and  ovarian  tumors,  and  the  relative  dis- 
tention of  dififerent  portions  of  the  cavity.  Measurements  may  be  made 
either  with  a  tape-measure,  or  with  calipers.  The  chief  measurements  are 
the  following : 

Circumference  at  umbilicus  or  at  highest  point  of  abdomen. 

Distance  from  ensiform  process  to  symphysis  pubis. 

Distance  from  ensiform  process  to  umbilicus. 

Distance  from  umbilicus  to  symphysis. 

Distance  from  umbilicus  to  anterior  superior  spinous  process  of  ilium  of 

either  side. 
Distance  from  linea  alba  to  corresponding  spinous  process  of  vertebra. 

By  repeating  these  measurements  at  intervals,  the  degree  and  manner 
of  the  growth  of  the  abdomen  may  be  watched.  Thus,  one-half  of  the 
abdomen  may  grow  more  and  faster  than  the  othei*,  or  the  distance 
between  xyphoid  process  and  symphysis  ma^^  vary,  according  to  the  posi- 
tion of  the  tumor  on  one  side  or  the  other. 

All  measurements  should  be  taken  on  the  bare  skin,  after  evacuation 
of  bladder  and  rectum.  The  patient  occupies  the  recumbent  position  ;  the 
erect  posture  is  neither  so  convenient  nor  decent,  and  offers  no  advan- 
tages except  the  greater  projection  of  the  abdomen,  which  may  mislead 
the  examiner.  The  tape-measure  should  be  exactly  contiguous  to  the 
skin  and  not  indent  it ;  a  flexible  lead  measure  may  be  usefully  employed 
to  obtain  the  exact  dimensions  and  shape,  like  a  cast,  of  one-half  of  the 
abdominal  outhne.  Hegar  and  Kaltenbach  point  out  that  in  ascites  and 
tympanites  the  curved  line  is  that  of  a  circle,  while  in  abdominal  tumors 
the  line  is  irregular  or  like  the  segment  of  a  cone. 

I.  Aspiration  of  Abdominal  and  Pelvic  Tumors. 

It  is  frequently  impossible  to  make  a  diagnosis  of  the  nature  of  an 
abdominal  or  pelvic  tumor,  whether  its  contents  are  soHd  or  fluid,  and 


118 


GYNECOLOGICAL    EXAMINATION. 


if  the  latter,  whether  it  is  serum  or  pus  or  blood,  by  the  rational  signs 
and  diagnostic  means  (palpation,  percussion,  indagation,  etc.)  already  de- 
scribed. Fortunately,  we  have  in  the  exploring  needle  an  instrument 
which  enables  us  to  solve  the  problem  in  a  large  proportion  of  cases.  This 
instrument  has  been  in  use  many  years,  and  consists  in  a  slender  hollow 
needle  not  larger  than  a  thick  sewing-needle,  and  from  two  inches  to  six 
inches  long,  which  is  thrust  into  the  tumor,  and  through  which  a  drop  or 
more  of  the  fluid  oozes,  if  there  be  fluid  in  the  growth.  Such  minute 
punctures  are  not  productive  of  harm  in  so  far  as  the  mere  wound  is 
concerned.  But  they  are  often  followed  by  serious  results  in  conse- 
quence of  the  entrance  of  air  through  the  open  tube,  the  ensuing  decom- 
position of  the  cyst-contents,  and  speedy  septicemia  and  death.     Besides, 

in  many  instances,  the  fluid 
is  too  thick  or  the  intra- 
cystic  pressure  not  suf- 
ficiently strong  to  force  the 
fluid  through  the  needle, 
and  the  diagnosis  therefore 
fails.  For  these  reasons  a 
complicated  contrivance 
called  an  aspirator  has  been 
devised,  which  permits  the 
removal  of  as  much  of  the 
fluid  as  is  desired  with  the 
absolute  exclusion  of'  air. 
The  instrument  now  in  com- 
mon use  is  that  of  Dieula- 
foy  or  one  of  its  modifica- 
tions. It  consists  of  a  syr- 
inge with  double  current 
stopcock,  one  current  lead- 
ing to  a  flexible  tube  to 
which  the  hollow  needle  is 
attached,  the  other  to  a  sec- 
ond tube,  one  end  of  which 
empties  in  an  air-tight  bottle^ 
into  which  the  fluid  removed 
from  the  tumor  is  pressed 
by  simply  closing  the  re- 
spective tube  when  the  syr- 
inge has  been  drawn  full,  and  pushing  down  the  piston  of  the  syringe. 

The  aspirations  may  be  either  partial,  for  diagnosis  only,  or  be  con- 
tinued until  the  tumor  is  emptied  of  its  fluid  contents.  There  are  three 
or  four  needles  of  different  sizes  with  each  instrument,  the  smallest  of 
which  is  about  as  thick  as  a  large  sewing-needle  (for  thin  fluids),  the  lar- 
gest larger  than  a  thick  knitting-needle  (for  thick  fluids,  like  pus  and  some 
ovarian  fluids). 


Pig.  71.— Modified  Dieulafoy's  Aspirator. 


ASPIRATION    OF    ABDOMINAL    AND    PELVIC    TUMOPvS.         119 

The  abdominal  tumors  which  most  frequently  defy  the  ordinary  diag- 
nostic i-esources  ai-e  ovarian  cysts,  cysts  of  the  broad  Hgament,  and  fibro- 
cysts  of  the  uterus.  The  differential  diagnosis  between  these  three  varie- 
ties is  often  a  matter  of  the  greatest  difficulty.  Only  by  a  microscopical 
and  chemical  examination  of  the  fluid  removed  by  the  aspirator  can  the 
diagnosis  be  made  in  many  cases,  and  upon  this  depends  the  treatment, 
which  in  these  cases  is  usually  a  question  of  life  or  death.  In  ovarian 
cysts  the  fluid  is  generally  straw-colored,  often  brownish  like  chocolate, 
viscid,  coagulating  by  heat  and  nitric  acid,  containing  a  large  amount  of 
albumen  ;  the  microscope  shows,  besides  pavement  epithelium  and  granu- 
lar and  fatty  matter,  a  peculiar  granular  cell,  the  "  ovarian  corpuscle " 
first  discovered  by  Drysdale,  of  Philadelphia,  and  by  him  declared  path- 
ognomonic. The  fluid  of  cysts  of  the  broad  ligament  is  mostly  clear,  like 
water,  not  viscid,  contains  no  granular  cells,  and  does  not  coagulate,  pos- 
sessing only  a  rather  mystical  albuminoid  substance,  the  metalbumen. 
Fibro-cysts  of  the  uterus  again  contain  a  light  yellow,  thin,  non-viscid 
fluid,  which  possesses  no  special  characteristics.  Other  tumors  resembling 
those  mentioned  are  cysts  of  the  liver,  kidney,  mesentery,  and  hydatid 
growths.  Cysts  of  the  liver  yield  a  yeUow  fluid,  in  which  the  microscope 
detects  liver-cells  in  a  more  or  less  perfect  condition.  (I  have  met  with 
one  such  case,  and  made  the  diagnosis  in  the  manner  indicated.)  Hydatid 
cysts  are  recognized  by  the  peculiar  booklets  of  the  parasite,  seen  under  the 
microscope  ;  and  the  fluid  from  cysts  of  the  kidney  may  show  the  presence 
of  urea.  Fluid  from  cysts  of  the  mesentery,  so  far  as  I  know,  possess  no 
characteristic  chemical  or  microscopical  distinctness.  Besides  these  actual 
tumors,  there  are  other  conditions  of  the  abdominal  cavity  which  simulate 
tumors,  and  require  the  aspirator  needle  to  make  the  differential  diagno- 
sis. Such  are  ordinary  ascites,  encysted  peritoneal  abscess,  and  extra- 
uterine pregnancy  with  death  of  the  fetus.  The  non-viscidity,  clear,  veiy 
light  yellow  color  of  the  fluid  and  its  coagulation  on  standing,  will  seiwe  to 
point  out  ascites,  without  the  microscope,  which  would  reveal  nothing 
except  perhaj)s  large  tessellated  epithelium  from  the  f»eritoneum.  The 
withdrawal  of  jdus  in  encysted  abscess  would  show  the  presence  of  suj)pu- 
ration,  if  not  its  precise  origin  or  situation.  In  old  extra- uterine  preg- 
nancy the  diagnosis  is  less  easy  ;  pus  may  be  found,  but  in  several  cases 
the  "  pathognomonic  "  ovarian  corpuscle  has  also  been  detected.  Diysdale 
himself  claims  to  be  able  to  decide  any  case  in  the  fluid  of  which  he  him- 
self discovers  the  corpuscle  to  be  ovarian,  and  he  has  never  missed,  I  be- 
lieve ;  but  others  have  not  been  so  successful,  and  have  found  the  cor- 
puscle in  the  fluid  from  abdominal  pregnancy  and  uterine  cysts. 

So  far  as  the  differential  diagnosis  by  the  microscope  between  unilocular 
ovarian  cysts  and  cysts  of  the  broad  ligament  is  concerned,  Garrigues,  in 
his  recent  elaborate  article  in  the  American  Journal  of  Obstetrics  for  Jan- 
uary, April,  and  July,  1882,  says  that  there  is  no  absolute,  vvfailing  sign 
by  which  the  fluid  from  these  two  varieties  of  cysts  can  be  distingriished. 
The  same  may  be  said  to  hold  good  for  many  fibrocysts  of  the  uterus.  It 
is  only  by  repeated  careful  examination  and  thorough  weighing  of  the 


120  GYNECOLOGICAL    EXAMINATION. 

testimony  for  either  side  that  a  correct  diagnosis  may  often  be  reached  in 
these  doubtful  cases. 

In  pelvic  tumors,  which  are  detected  and  reached  only  or  best  through 
the  vaoina,  the  aspirator-needle  is  often  quite  as  valuable  an  aiixiliary  to 
diagnosis.  It  enables  us  to  determine  whether  a  tense  elastic  tumor  in  the 
broad  ligament  contains  serum,  is  in  fact  a  beginning  ovarian  or  ligament 
cyst,  or  whether  its  contents  are  deep-seated  pus.  It  reveals  to  us  the 
nature  of  a  large,  doughy,  retro-uterine  swelling,  whether  it  is  the  result 
of  an  intraperitoneal  effusion  of  blood  (hematocele),  or  whether  pus  has 
formed  in  an  exudation  of  plastic  lymph.  It  enables  us,  finally,  to  de- 
tect the  cause  of  the  rigors,  increased  pulse  and  temperature,  and  gen- 
eral cachexi.a,  in  a  patient  with  an  old  obscure  pelvic  cellulitis  in  one 
broad  ligament  or  the  other,  by  showing  us  that  the  pecuhar  boggy  feel  of 
the  exudation  tumor  and  its  persistence  in  spite  of  aR  treatment  are  due 
to  the  presence  of  a  small  quantity  (often  not  more  than  one  ounce)  of 
thick  pus  deep  within  the  exudation,  the  removal  of  which  through  that 
very  aspirator-needle  rapidly  cures  the  patient,  I  have  recently  been  using 
the  aspirator  in  this  particular  class  of  cases  with  the  most  gratifying 
results,  having  ciu-ed  previously  intractable  cases  of  pelvic  cellulitis,  in 
which  the  swelhng  had  persisted  for  several  months  and  the  cause  had  not 
been  suspected,  within  a  few  weeks  by  simply  removing  an  ounce  or  two 
of  pus  per  vagmam. 

The  introduction  of  the  aspirator-needle  is  exceedingly  simple.  If  it 
is  desired  to  aspirate  an  abdominal  tumor,  it  is  merely  necessaiy  to  select  a 
spot  where  percussion  shows  the  absence  of  intestines  or  other  vital  organs, 
and  where  palpation  renders  the  presence  of  fluid  probable,  and  there 
plunge  the  needle  (using,  of  course,  the  finest  size  likely  to  be  successful) 
to  its  hilt  into  the  growth.  Accordingly  as  the  object  is  diagnosis  or  re- 
moval of  all  the  fluid,  will  the  aspiration  be  confined  to  one  syringeful,  or 
continued  until  the  cyst  is  empty.  After  withdrawing  the  needle  a  bit  of 
adhesive  plaster  is  placed  over  the  minute  puncture. 

In  spite  of  the  ease  with  which  the  aspiration  through  the  abdominal 
wall  is  made,  the  small  size  of  the  opening  (if,  as  always  should  be  done, 
the  smallest  sized  needle  is  used),  and  the  tolerance  of  the  peritoneum  to 
injuries  nowadays,  a  number  of  instances  have  been  reported  in  which 
careful  aspiration  of  ovarian  tumors  was  followed  by  peritonitis,  decom- 
position of  the  contents  of  the  tumor,  and  death.  I  myself  had  such  a 
case,  and  was  obhged  to  perform  ovariotomy  in  the  height  of  a  furious 
septic  peritonitis,  prolonging  life  by  only  six  days.  Consequently  it  was 
proposed  by  Dr.  Henry  F.  Walker,  of  New  York,  always  to  use  the  hypo- 
dermic syringe  for  diagnostic  aspiration,  and  this  is  the  instrument  now 
almost  solely  employed  for  the  purpose.  Ordinary  ovarian  fluid,  of  not 
too  great  viscidity,  w'ill  flow  through  the  hypodermic  needle.  Even  from 
this  slight  injury  one  case  of  (not  fatal)  peritonitis  has  been  reported  by 
Fauntleroy,  of  Virginia. 

Through  the  vagina  the  operation  is  slightly  more  difScult,  in  accord- 
ance with  the   diminished  accessibihty  of   the  swelling.     The   aspirator- 


ASPIRATIOlSr    OF    ABDOMINAL    AND    PELVIC    TUMOES. 


121 


needle  may  either  be  passed  in  on  the  finger,  care  being  taken  to  avoid 
injuring  the  woman  unnecessarily  or  pricking  one's,  own  finger  (this 
may  be  avoided  by  guarding  the  needle  point  with  a  small  cork  which  is 
slipped  off  when  the  vaginal  roof  is  reached)  ;  or  the  vaginal  walls  may 
be  freely  exposed  with  a  Sims  speculum  and  the  needle  inserted  through 
it  in  the  spot  previously  determined  by  the  touch  and  palpation.  The 
important  point  is  to  make  out  the  exact  spot  where  the  presence  of  fluid 
seems  most  probable,  and  remembering  it,  insert  the  needle  there,  and 
gently  but  firmly  thrust  it  upward  in  the  direction  in  which  previous 
exploration  has  shown  the  bulk  of  the  swelling  to  be  situated.  In  in- 
serting the  needle  care  should  be  taken  to  avoid  jDuncturing  one  of  the 
large  arterial  branches  whidi  are  easily  felt  pulsating  in  the  roof  of  the 
vagina.  When  the  needle  has  penetrated  as  far  as  seems  advisable,  judg- 
ing by  the  size  of  the  tumor,  the  piston  of  the  syringe  may  be  di'a\\Ti  back 
(it  is  well  to  have  an  assistant  to  do  this,  while  the  opei'ator  steadies  the 
needle  and  tube),  and  the  expression  of  the  contents  into  the  bottle  will 
show  whether  the  tumor  contains  fluid  and  what  it 
is.  If  the  first  attempt  is  unsuccessful,  the  needle 
may  be  thrust  in  a  little  deeper,  or  in  a  different 
direction  ;  indeed,  I  have  repeatedly  reintroduced 
the  needle  as  often  as  seven  or  eight  times  at  the 
same  sitting,  finding  a  little  pus  at  each  puncture, 
until  the  w^hole  supply  was  exhausted.  In  such 
cases  no  doubt  there  were  a  number  of  small  ab- 
scesses. 

In  passing  the  needle  through  the  vagina  into 
a  swelling  above  the  vaginal  roof  I  decidedly  prefer 
to  guide  the  needle  on  my  finger,  because  by  so 
doing  I  can  be  very  much  more  certain  that  I  am 
introducing  it  in  the  right  direction,  and  how  far  it 
is  inserted,  besides  being  able  to  steady  the  swelling 
and  press  it  gently  down  against  the  needle  with  the 
other  hand  on  the  abdomen. 

Generally,  when  the  needle  has  struck  pus,  the 
sudden  cessation  of  all  resistance  is  marked,  and  the 
point  can  be  freely  moved  about  in  the  cavity  of  the 
abscess,  if  it  contains  at  least  half  an  ounce.  Often 
the  intervening  plastic  lymph  is  so  dense  as  to 
creak  almost  like  cartilage  as  the  needle  is  forced  through  it. 

In  order  to  avoid  the  cumbei-some  apparatus  of  a  Dieulafoy's  aspirator, 
I  have  had  a  glass  syringe  made  holding  four  ounces,  the  nozzle  of  which 
is  provided  with  a  stopcock.  To  this  nozzle  is  attached  a  slender  metal 
tube,  four  inches  long,  also  with  a  stopcock,  and  to  this  tube  the  needle, 
each  being  separate.  My  method  of  jDrocedure  is  usually  the  following  : 
Having  selected  the  spot  where  I  think  fluid  is  most  hkely  to  be  found,  I 
attach  the  slender  tube  with  the  needle  (4  inches  long)  to  my  ordinary 
hypodermic  syringe  (to  the  tip  of  which  the  tube  has  been  made  to  fit), 


Fig.  72. — Aspirator-syringe, 
with  Long,  Slender  Needle  and 
Hypodermic  Syringe  Attach- 
ment (P.  F.  M.). 


122  GYNECOLOGICAL   EXAMINATION. 

and  have  now  an  aspirator  10  inches  long  (needle  4  inches,  tube  with 
stopcock  4  inches,  syringe  2  inches),  which  I  introduce  on  my  finger  into 
the  vagina.  The  needle-point  is  guarded  by  a  cork,  which  I  slip  off  when 
the  chosen  spot  at  the  vaginal  roof  is  reached,  and  the  needle  is  driven 
into  the  tumor.  The  stopcock  is  now  opened,  and  the  syringe-piston 
drawn  back.  If  fluid  follows,  I  close  the  stopcock,  remove  the  hypodermic 
syringe,  attach  the  large  syringe,  and  withdraw  all  the  fluid.  In  this 
way  air  is  prevented  from  entering  the  tumor,  by  closing  the  stopcock 
before  detaching  the  hypodermic  syringe  ;  and  I  am  enabled  to  follow 
the  diagnostic  aspiration  by  the  immediate  removal  of  the  fluid  vnthout 
reintroduction  of  the  needle,  if  thought  advisable.  This  apparatus  is 
cheap,  serviceable,  and  convenient  in  all  cases  where,  as  is  usually  the  case 
in  these  obscure  pelvic  abscesses  and  small  cysts,  the  quantity  of  fluid  to 
be  removed  is  only  a  few  ounces. 

Mr.  Philip  H.  Schmidt,  instrument-maker,  of  this  city,  has  made  for 
me  a  very  convenient  and  portable  case  containing  the  instruments  above 
named,  with  the  substitution  of  a  smaller  syringe,  holding  but  one  ounce, 
for  the  large  one,  and  with  the  addition  of  several  long  needles,  a  trocar, 
and  a  sharp  director-needle. 

I  have  thus  far  met  with  no  unpleasant  reaction  in  cases  of  pelvic  ab- 
scess after  this  procedure.  The  exclusion  of  air,  the  small  size  of  the  nee- 
dle, and  probably  the  hardened  character  of  the  tissues  may  account  in 
part  for  this  immunity.  Other  operators  report  precisely  the  same  ab- 
sence of  reaction. 

But  in  one  case  of  doubtful  pelvic  cyst,  where  vaginal  aspiration  in  my 
office  showed  the  mass  to  be  an  ovarian  polycyst,  I  was  subsequently  in- 
formed that  a  violent  peritonitis  set  in,  which  confined  the  patient  to  her 
bed  for  a  long  time.  Hence  I  should  certainly  advise  against  this  practice 
in  intraperitoneal  cysts,  the  walls  of  which  are  not  agglutinated  to  the  pelvic 
peritoneum.  In  cysts  of  the  broad  ligament  (the  fluid  of  which  is  bland) 
and  pelvic  abscesses  there  is  but  httle  danger  attached  to  it. 

I  have  practised  this  diagnostic  aspiration  in  the  outdoor  chnic  and 
once  (in  a  case  of  small  cyst  of  the  broad  ligament)  in  my  office ;  but  I 
should  certainly  advise  it  always  to  be  done  at  the  home  of  the  patient. 
Indeed,  this  is  usually  indispensable,  as  such  patients  are  generally  little 
able  to  walk  about.  Hot  applications  to  the  hypogastrium  and  rest  in 
bed  for  a  day  or  two  are  useful  prophylactics  after  the  operation.  In  case 
of  pain  a  hypodermic  or  suppository  of  morphine  should  be  given. 

Examination  by  Reflected  Light. 

Ordinary  bright  daylight  answers  every  purpose  for  the  inspection  of 
the  genital  organs,  both  external  and  internal.  But  it  frequently  happens 
that  the  daylight  is  less  bright  than  usual,  or  the  window  through  which 
it  shines  is  inconveniently  situated  in  respect  to  the  position  of  the  pa- 
tient, who  for  reasons  of  time  or  expediency  cannot  be  shifted  to  a  better 
location ;  or  an  examination  or  operation  may  have  to  be  done  by  artificial 


EXAMINATION    BY    REFLECTED    LIGHT. 


123 


light.  For  the  pui-pose  of  throwing  the  sunlight  on  a  given  sj^ot — for  in- 
stance, into  the  recesses  of  the  abdominal  or  pelvic  cavity — a  common  concave 
hand  or  frontal  mirror  may  be  used.  The  same  instrument  also  answers  veiy 
well  for  the  reflection  of  artificial  light,  and  has  the  advantage  over  more 
powerful  reflectors  in  being  easily  portable.  In  the  absence  of  a  mirror  a 
very  simple  and  fairly  efficient  reflector  to  a  limited  extent  is  rapidly  con- 
structed by  fastening  a  bright  pewter  or  silver  table-spoon  against  a  can- 
dle with  the  bowl  on  a  level  with  the  flame,  as  shown  m  Fig.  73  ;  or,  a 
plain  reflector  of  tin  may  be  slipped  over  a  German  student's  lamp,  or 
more  elaborate  reflectors  of  glass  or  polished  metal  may  be  attached  to  ex- 
tensible gas-pipes.  I  have  found  the  reflector  shown  in  Fig.  75  to  answer 
every  purpose  of  efficiency  and  economy. 


Fig.  7o.  Fig.  74.  Fig.  75. 

Fig.  73. — Improvised  Reflector.     D,  E,  pieces  of  cork  cut  to  fit  the  candle,  for  the  spooa-handle  to  rest 
against.     (Leblond.) 

Figs.  74  and  75. — Reflectors  for  Specular  Examination.     (Leblond.) 


A  very  neat  portable  electric  light  has  recently  been  introduced  by  the 
Excelsior  Manufacturing  Co.  of  New  York.  The  small  size  of  the  burner 
and  the  comparative  absence  of  reflected  heat  permit  the  introduction  of 
the  incandescent  tij)  into  the  vagina  through  a  speculum,  and  I  have  found 
it  of  decided  benefit  in  lighting  up  that  canal  on  dark  days.  The  construc- 
tion of  the  battery  is  exceedingly  simple,  and  it  is  not  very  expensive.  It 
is  shown  in  Fig.  76.  The  size  of  the  battery  with  case  is  5^"  by  4"  by  1;^", 
it  being  thus  really  a  pocket  battery. 

By  a  clear,  well-reflected  hght  every  examination  and  operation  may 
be  performed  as  well  as  by  daylight.  I  once  assisted  at  an  operation  for 
laceration  of  the  cervix  uteri  by  artificial  reflected  light,  and  was  exceed- 


124 


GYNECOLOGICAL    EXAMINATIOlSr. 


ingly  pleased  at  the  briglitness  of  the  field  of  operation.  In  judging  of 
the  exact  color  of  the  vagina  and  cervix,  clear  bright  sunlight  is  preferable 
to  yellow  candle  or  gaslight. 


"^//,\v^" 


Fig.  76.— Haid  Portable  Electric  Light. 


GrYNECOLOGICAIi    CaSE-SCHEDULE. 

A  systematic  course  of  inquiry  and  examination,  both  oral  and  phys- 
ical, is  quite  as  important  in  taking  the  history  and  making  the  diagnosis 
of  a  case  of  utero-ovario-pelvic  disease  as  it  is  in  any  other  branch  of  prac- 
tical medicine.  For  this  purpose  a  printed  schedule  is  eminently  useful, 
which  when  filled  out  affords  besides  a  full  record  of  the  case  for  future 
reference.  The  form  printed  on  the  next  page  is  one  which  I  have  been 
using  for  ten  j'ears,  and  have  found  to  answer  the  needs  of  a  miscella- 
neous gynecological  practice.  For  special  operations,  such  as  ovariotomy, 
laparo-hysterotomy,  etc.,  separate  schedules  should  be  prepared  ;  those  of 
Spencer  Wells  or  H.  Lenox  Hodge  are  excellent.  More  elaborate  sched- 
ules, giving  a  full  page  or  more  to  each  case,  may  be  prepared  ;  but  I  hava 
found  that  in  busy  practice  such  large  blanks  are  rarely  filled  out. 

Three  or  four  of  such  forms  under  one  top-heading  may  be  printed  on 
one  sheet  of  the  Case-book,  and  the  book  thus  prepared  will  not  exceed  a 
convenient  size  for  office  use.  The  one  I  use  measures  eleven  inches  in 
breadth,  and  fifteen  inches  in  length,  and  has  three  forms  to  the  double 
page,  under  one  general  top-heading. 

When  the  examination  has  been  concluded,  the  physician  should  give 
his  opinion  of  the  patient's  case  in  as  few  words  as  possible,  avoiding  all 
ambiguity,  confusing  medical  phrases,  and  unnecessary  explanations.  In- 
telligent patients  generally  desire  to  know  their  exact  condition,  and  it 
may,  therefore,  be  proper  and  wise  for  the  physician  to  gratify  the  patient's 
natural  curiosity  by  showing  her,  by  a  diagram,  what  that  condition  is,  if 
his  judgment  tells  him  that  she  is  a  proper  person.  I  have  a  blackboard 
in  my  office  for  the  purpose. 

When  asked  as  to  the  prognosis,  the  physician  should  neither  exagger- 
ate the  severity  of  the  case  nor  the  urgency  for  treatment  with  the  (to  a 
certain  degree  justifiable)  object  of  inducing  the  patient  to  take  treatment 
which  she  greatly  needs  and  might  defer,  if  her  case  were  not  strongly 


GYNECOLOGICAL    CASE-SCHEDULE. 


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126  GYNECOLOGICAL    EXAMINATION^. 

put  to  her ;  neitlier  should  he  undervalue  the  affection  and  the  time  which 
it  may  take  to  effect  a  cure  or  procure  relief.  In  the  former  case  the 
patient  might  consult  another  physician  and  tell  him  of  the  grave  opinion 
given  by  the  first  gentleman,  vs^hich  the  second  finds  unwarranted  by  the 
facts ;  and  in  the  latter  instance,  if  the  case  turns  out  more  tedious  and 
intractable  than  was  expected,  the  patient  holds  the  physician  responsible 
for  her  disappointment,  and  blames  him  herself  and  to  her  friends  accord- 
ingly. It  is  always  advisable  to  acquaint  the  patient  with  the  gravity  of 
her  case  (without  unnecessarily  alarming  her),  and  tell  her  whether  a  speedy 
or  eventual  cure  may  be  expected,  or  whether  her  case  is  but  little  likely 
to  be  benefited.  In  intractable  chronic  affections,  like  areolar  hyper- 
plasia, chronic  ovaritis,  chronic  pelvic  peritonitis  and  cellulitis,  it  is  always 
well  to  tell  patients  that  much  good  can  be  done  them  and  some  improve- 
ment obtained  by  persistent  local  treatment  for  several  months,  but  that  a 
complete  cure  may  perhaps  never  be  achieved.  Of  course  I  do  not  advise 
that  the  few  remaining  months  of  a  patient  suffering  from  cancer  should 
be  embittered  by  her  being  told  of  her  hopeless  condition  as  soon  as  it  is 
discovered,  unless  she  positively  demands  the  truth,  or  family  reasons 
require  that  she  be  undeceived  in  her  hope  of  recovery.  The  relatives 
should,  however,  always  be  informed  of  the  fact,  and  the  futility  of  all  but 
palliative  remedies. 


PART  II. 

MINOR   GYNECOLOGICAL   MANIPULATIONS 
AND   APPLICATIONS. 


I.   CATHETERIZATION. 


The  indications  for  removing  the  urine  of  a  woman  by  artificial  means 
need  hardly  be  sj^ecified,  since  they  are  usually'  comprised  in  the  one  fact — 
the  inabiHty  of  the  woman  to  empty  her  bladder  herself.  There  are,  how- 
ever, four  other  conditions  in  which  it  may  be  desirable  to  remove  the 
urine  by  the  catheter,  viz.  :  1,  when  the  patient  is  unable  to  pass  urine  in 
the  ordinary  erect  position,  and  it  is  important  to  prevent  the  urine  from 
touching  the  external  genitals,  as  would  be  the  case  if  she  passed  it  in  the 
dorsal  supine  position  (after  the  operation  for  laceration  of  the  peri- 
neum) ;  2,  when  the  bladder  is  to  be  preserved  from  distention,  as  after 
the  operation  for  vesico-vaginal  fistula,  when  a  permanent  catheter  is  usu- 
ally introduced  until  the  wound  is  healed  ;  3,  when  it  is  intended  to  se- 
cure a  specimen  of  urine  entirely  free  from  utero-vagino-vulvar  or  lochial 
discharge,  as  for  microscopic  examination  ;  4,  when  the  woman  is  under 
an  anesthetic.  The  mere  fact  that  the  patient  claims  not  to  be  able  to 
pass  urine  does  not  prove  that  the  bladder  is  distended  ;  she  may  have 
passed  it  unknowingly  while  at  stool,  or  the  kidneys  may  not  be  doing 
their  duty,  or  the  skin  and  other  emunctories  may  have  temporarily  sup- 
plied their  place.  Neither  does  the  statement  of  patient  or  nui'se,  that 
the  urine  has  been  regularly  passed,  positively  demonstrate  the  empti- 
ness of  the  bladder.  It  not  unfrequently  happens  after  confinement  or 
operation  that  the  nurse  or  patient,  or  both,  make  this  assertion,  and  the 
physician,  seeking  the  cause  of  the  feverish  condition  of  his  patient,  finds 
the  bladder  distended  nearly  to  the  umbilicus,  with  the  urine  drip23ing 
away,  like  the  overflow  from  a  tank,  and  removes  with  the  catheter  pints 
of  foul,  decomposed  urine.  There  was  temporary  retention  from  compres- 
sion and  edema  or  spasm  at  the  neck  of  the  bladder,  or  the  elongated  ure- 
thra (during  pregnancy)  became  flexed  on  the  descent  of  the  utei-us  after 
delivery,  and  the  flow  of  urine  was  thus  obstructed  (Olshausen's  explana- 
tion of  the  frequent  temporary  retention  of  urine  immediately  after  de- 


128  MINOR    GYNECOLOGICAL    MANIPULATIONS. 

livery)  ;  tlie  detrusor  vcsicse  tlien  became  paralyzed,  unaided  as  it  was  by 
pressure  from  the  now  flabby  abdominal  muscles,  and  the  bladder  con- 
tinued to  enlarge  until  the  sphincter-like  fibres  at  the  neck  of  the  bladder 
yielded,  and  allowed  the  escape  of  a  few  drops.  Such  a  condition  as  this 
cannot  miss  detection  if  the  jDroper  external  examination  is  made.  In  no 
case,  therefore,  in  which  there  is  any  susj^icion  of  trouble  in  the  function 
of  micturition  should  a  careful  physical  examination  of  the  vesical  region 
by  palpation  and  percussion  be  omitted. 

No  person  acquainted  with  the  anatomy  of  the  parts,  need  be  told  how 
to  introduce  a  catheter  into  the  female  bladder  when  the  meatus  urina- 
rius  is  exposed  to  sight  ;  gentleness  and  caution  in  the  introduction  and 
removal  are  the  only  directions  to  be  given.  But  to  find  the  meatus  and 
introduce  the  catheter  by  the  touch  alone,  is  quite  another  and  more  diffi- 
cult matter,  requiring  a  touch  practised  in  detecting  the  location  of  the 
ojDening.  This  knowledge  is  obtained  only  by  frequent  education  of  the 
tip  of  the  index-finger  in  the  peculiar  sensation  imparted  by  the  small 
circular  ring  of  the  meatus.  The  acquisition  of  this  faculty  is  by  no 
means  unimportant,  for  it  enables  us  to  avoid  the  always  disagreeable  ex- 
posure of  the  person,  and  may  at  times  be  indispensable  when  edema  of 
the  labia  interferes  with  inspection  of  the  vestitbule,  or  he  presence  of  sut- 
ures in  the  perineum  renders  a  separation  of  the  labia,  for  the  puipose  of 
exposing  the  meatus,  unadvisable.  The  rule  holds  good  in  this  maneuvre, 
as  in  every  other  performed  on  the  female  genital  organs,  that  while  a 
necessary  exposure  should  never  be  omitted  for  mere  reasons  of  prudery, 
such  exposure  should  not  be  inflicted  when  the  examination  or  manipula- 
tion can  be  as  well  performed  under  the  clothes.  The  practitioner  should, 
therefore,  accustom  himself  to  the  touch  of  the  female  ui'inary  meatus  in 
order  that  he  may  recognize  it  when  he  is  called  upon  to  empty  a  pa- 
tient's bladder. 

Standing  somewhat  to  the  side  of  the  patient,  who  lies  with  thighs 
separated  (not  necessarily  also  elevated),  the  index-finger  of  either  hand 
is  slipped  from  the  perineum  into  the  vagina,  and  then  out  again  over 
the  concave  border  of  the  symphysis  of  the  pubic  arch  (where  it  glides 
along  the  bulbous  projection  of  the  urethra)  on  the  vestibule,  where  it 
searches  for  a  small  deiDression  barely  large  enough  to  admit  the  very  tip 
of  the  finger.  This  small  circular  opening  is  situated  about  one-third  of 
the  distance  up  the  vestibule,  the  urethra  curving  slightly  upward  ;  it  is 
recognized  by  the  comparatively  sharp  ring  formed  by  the  edge  of  the 
meatus  when  it  is  distended  by  the  finger-tijD.  It  is  the  detection  of  this 
small  ring  by  the  touch  which  constitutes  the  only  difficulty  in  the  ma- 
neuvre. The  finger  having  found  the  meatus,  presses  gently  against  it, 
with  the  volar  surface  upward  ;  the  catheter  (metal  or  elastic  ;  if  the  lat- 
ter, with  or  without  mandrin)  is  seized  in  the  three  fingers  of  the  other 
hand  (the  index  closing  the  mouth)  and  passed  on  the  index-finger  into 
the  meatus,  precisely  as  the  sound  is  passed  into  the  uterus.  When  the 
tip  of  the  catheter  is  felt  to  enter  the  urethra  the  other  end  is  depressed, 
and  the  instrument  gently  pushed  forward  until  the  cessation  of  even 


CATHETERIZATION.  129 

slight  resistance  shows  that  it  has  entered  the  bladder.  The  finger  is  now 
removed  from  the  mouth  of  the  catheter,  and  the  urine  allowed  to  escape 
into  the  vessel  held  ready  for  it.  I  prefer  a  cup  or  bowl  for  this  purpose, 
which  can  be  placed  between  the  thighs  and  does  not  occupy  as  much 
space  as  a  chamber  vessel.  When  the  urine  ceases  to  flow,  gentle  press- 
ure may  be  made  over  the  pubis,  or  the  catheter  pushed  in  a  Httle  deejDer 
or  withdrawn  a  short  distance  in  order  to  catch  whatever  urine  may  have 
been  retained  in  diverticles  of  the  bladder.  When  the  last  drop  has  es- 
caped, the  catheter  is  again  seized  between  the  three  fingers,  with  the  in- 
dex on  its  mouth  in  order  to  prevent  the  few  drops  of  urine  in  the  cathe- 
ter from  soiling  the  clothes,  and  gently  withdrawn  ;  when  the  point  is  held 
over  the  vessel  the  finger  is  removed  from  the  mouth  and  a  few  drops  al- 
ways escape  from  the  other  end.  The  introduction  of  the  catheter  into  the 
normal  urethra  is  usually  painless,  with  the  exception  of  a  shght  disagTee- 
able  sensation  as  it  passes  into  the  bladder.  Its  withdrawal  often  gives 
somewhat  more  pain  when  the  circular  muscular  fibres  at  the  neck  of  the 
bladder  contract  on  it  and  oppose  its  removal ;  cessation  of  traction  for  a 


Fig.  T7.— Sims'  Sigmoid  Catheter.  Tig.  "is.— Goodman-Skene's  Self -retaining  Catheter. 

few  moments  and  then  gentle,  steady  traction  will  usually  overcome  the 
obstacle.  In  irritable,  inflamed,  or  fissured  urethrse,  the  catheter  gives 
more,  even  decided  pain  ;  so  also  in  cystitis  when  its  point  strikes  the  waU 
of  the  bladder.  If  the  urine  ceases  to  flow  when  percussion  shows  that 
the  bladder  is  not  empty,  in  all  probability  the  eye  of  the  catheter  is 
choked  up  by  the  vesical  mucus,  which  can  be  removed  by  passing  the 
mandrin  into  the  catheter. 

In  some  women  the  vestibule  of  the  vagina  presents  several  little  shal- 
low depressions  (congenital  formations,  usually  associated  with  redundancy 
of  the  anterior  border  of  the  hymen  or  its  remains)  which  may  confuse 
the  practitioner  in  his  search  for  the  meatus,  the  only  opening  or  irregu- 
larity in  the  normal  vestibule.  The  sharp  ring,  already  spoken  of,  will 
prove  the  distinguishing  mark.  At  times  the  meatus  is  situated  exactly 
on  the  edge  of  the  anterior  border  of  the  vaginal  orifice,  and  is  pushed 
slightly  within  the  orifice  by  the  finger,  thus  escaping  from  the  tip  of  the 
catheter  and  materially  increasing  the  difiiculty  of  its  introduction.  A 
loose  attachment  of  the  urethra  to  the  symphysis  pubis  is  probably  the 
reason  of  this  displaceability  of  the  meatus. 

Cases  suffering  from  a  purulent  or  infectious  discharge  from  the  va- 
gina form  an  exception  to  the  rule  of  not  exj)osing  the  jDatient  for  any 
manipulation  practicable  under  the  clothes.  By  means  of  the  finger  the 
infectious  substance  may  be  carried  to  the  meatus  and  thence  into  the 
bladder  by  the  catheter,  and  an  acute  cystitis  be  the  result.  For  this  rea- 
9 


130  MINOR    GYNECOLOGICAL    MANIPULATIONS. 

son  it  is  usually  advisable  to  introduce  the  catheter  in  lying-in  women  by 
sio-ht  rather  than  by  touch  ;  for  Olshausen,  who  has  investigated  this  sub- 
ject, has  shown  that  acute  cystitis  is  not  unfrequently  produced  by  the  in- 
troduction of  lochial  fluid  into  the  bladder  on  the  catheter.  A  careful 
cleansing  of  the  external  genitals,  and  the  exposure  of  the  meatus  during 
the  catheterization  is  advisable.  The  same  rule  applies,  for  the  same  rea- 
son, after  a  perineum  operation  ;  and  also  if  the  practitioner  is  not  very 
skilful  in  finding  the  meatus,  but  endangers  the  union  of  the  rent,  in  his 
endeavors  to  touch  that  opening. 

After  the  operation  for  vesico-vaginal  fistula  it  is  customary  to  intro- 
duce a  self -retaining  catheter  until  the  stitches  have  been  removed  ;  this 
is  also  frequently  done  after  the  secondary  operation  for  lacerated  peri- 
neum, to  prevent  the  urine  from  touching  the  wound,  and  relieve  pa- 
tient and  physician  from  the  annoyance  of  frequent  catheterization. 
Sims'  sigmoid  catheter  (Fig.  77)  is,  undoubtedly,  the  best  instrument  of 
the  kind,  better  than  the  elastic  rubber  catheters,  which  are  liable  to 
slip  out  and  rapidly  become  foul.  The  sigmoid  catheter  requires  to  be 
removed  and  cleansed  every  day.  It  is  retained  by  its  pecuhar  shape, 
balancing,  as  it  were,  in  the  urethra.  A  vessel  between  the  thighs  of  the 
patient  receives  the  constantly  dropping  urine.  All  patients  do  not  bear 
these  self-retaining  catheters  well,  and  complaints  of  vesical  pain  and 
tenesmus  occasionally  require  the  removal  of  the  instrument  and  a  return 
to  frequent  catheterization  or  spontaneous  urination.  It  is  by  no  means 
absolutely  necessary  that  the  urine  should  constantly  escape  after  fistula 
operations  (Simon  allowed  his  patients  to  urinate  normally  at  frequent  in- 
tervals, and  other  operators  use  the  ordinary  catheter),  or  that  it  should  be 
kept  from  the  surface  of  a  freshly  united  perineum.  I  have  frequently  seen 
perfect  union  ensue,  both  after  the  primai-y  and  secondary  operation,  in 
cases  where  the  patients  urinated  at  will,  and  the  external  genitals  were 
merely  washed  by  a  gentle  stream  of  tepid  water  immediately  after  each 
evacuation  of  the  bladder. 

A  very  serviceable  instrument  is  the  self-retaining  catheter  of  Good- 
man, modified  by  Skene  (Fig.  78).  It  is  chiefly  used  in  cases  of  chronic 
cystitis,  when  it  is  desired  to  maintain  a  continuous  drain  of  urine  from 
the  bladder.  A  rubber  tube  attached  to  the  mouth  of  the  catheter  leads 
the  urine  into  a  vessel  at  the  bedside,  or  a  rubber  receptacle  worn  under 
the  clothing.  This  instrument  may  be  worn  for  months,  while  the  woman 
is  about  her  daily  avocation. 

n.  DILATATION    OF  THE  URETHRA. 

Although  really  one  of  the  minor  operations  of  gynecology,  the  dilata- 
tion of  the  female  urethra  is  discussed  in  this  connection  for  convenience 
sake. 

The  indications  for  the  operation  are  either  of  a  diagnostic  nature  (as 
already  referred  to)  or  for  therapeutical  purposes.  For  diagnosis,  the 
dilatation  is  performed  to  permit  the  introduction  of  the  finger  or  endo- 


DILATATION    OF    THE    UKETHRA.  131 

scope ;  for  tlierapeutical  purposes,  as  a  means  of  cure,  througli  distention 
of  the  canal  alone,  and  to  permit  the  free  introduction  and  exit  of  instru- 
ments and  fluids.  Thus,  in  cases  of  irritable  urethra  or  bladder,  or  fissure 
of  the  lu-ethra,  or  after  removal  of  urethral  caruncle,  or  in  chronic  cystitis, 
the  hyperdistention  of  the  urethral  walls  affords  a  very  efficient,  perhaps 
certain  mode  of  relief ;  further,  in  vesical  calculus,  dilatation  permits  the 
removal  of  the  entire  or  crushed  stone,  and  in  chronic  cystitis  the  fi'ee 
efflux  of  injected  fluid.  In  the  latter  condition,  besides,  the  free  drain, 
which  may  follow  thorough  dilatation  of  the  urethra  for  several  days,  gives 
at  least  temporary  relief. 

For  tenesmus  and  irritable  urethra  and  bladder,  a  distention  to  the 
largest  size  of  Peaslee's  dilators  will  usually  suffice,  and  will  occasion  com- 
paratively little  pain.  For  the  other  conditions,  the  urethra  should  be 
dilated  to  the  free  admission  of  the  index-finger,  an  operation  always  call- 
ing for  an  anesthetic. 

When  the  ui-ethra  has  been  dilated  to  its  full  dimensions,  the  diseased 
(inflamed  or  ulcerated)  spots  may  be  exjDosed  vnth  the  speculum  or  endo- 
scoj)e  (as  already  described  under  Examination  of  the  Bladder),  and  medi- 
cinal agents  be  directly  applied  to  them  through  the  tube. 

The  digital  exploration  of  the  vesical  mouths  of  the  ureters,  and  the 
practicability  and  utility  of  sounding  these  ducts  has  already  been  referred 
to  under  Digital  Examination. 

Operation. — The  dilatation  of  the  urethra  may  be  performed  either  by 
the  finger  or  by  instruments.  As  a  rule,  every  dilatation  must  be  begun 
by  instruments  until  the  tip  of  the  little  finger  can  be  introduced  :  thus, 
the  ordinary  dressing  forcejDS,  or  Peaslee's  or  Hanks'  or  Simon's  dilators 
are  introduced,  and  the  urethra  is  gently  stretched  to  the  width  of  the 
little  finger.  Although  in  apathetic  subjects  the  dilatation  may  be  per- 
formed without  an  anesthetic,  it  is  generally  advisable  to  put  the  pa- 
tient at  least  into  the  first  temporary  unconsciousness  attending  every 
anesthesia,  if  the  dilatation  is  to  be  pushed  farther  than  the  width  of  the 
little  finger. 

The  patient  being  anesthetized,  and  occupying  the  supine  joosition  on 
the  back,  the  forceps  or  dilators  are  gently  introduced  through  the  urethra 
into  the  bladder  and  gradual  dilatation  is  performed  until  the  urethra 
seems  sufficiently  large  to  admit  the  tip  of  the  little  finger.  Some  blood  may 
escape  during  this  process,  but  usually  no  visible  laceration  of  the  meatus 
is  produced.  The  tip  of  the  little  finger  is  then  engaged  in  the  meatus, 
and  gently  pressed  forward  by  a  half-pushing,  half-boring  motion  imtil  the 
constriction  at  the  meatus  is  passed,  often  suddenly  (with  more  or  less 
nicking  of  the  border),  and  the  finger  passes  the  slight  obstruction  at  the 
neck  of  the  bladder,  and  its  tip  enters  that  viscus.  Some  difficulty  is  oc- 
casionally produced  by  the  flexibility  of  the  little  finger  and  its  metacar- 
pal joint,  and  the  loose  attachment  of  the  urethra  to  the  pubic  arch  :  in 
such  cases  more  force,  usually  of  a  pushing  nature,  is  required,  or  the 
lU'ethra  must  be  supported  by  the  other  hand,  or  the  index-finger  takes 
the  place  of  the  little  finger  as  a  dilator.     If  it  is  desired  to  push  the  dila- 


132 


MINOR    GYNECOLOGICAL    MANIPULATIONS. 


tation  still  farther,  the  little  finger  is  withdrawn,  and  the  index  gently 
forced  into  the  bladder  in  the  same  manner,  with,  of  com'se,  more  or  less 
laceration  of  the  meatus  (generally  upward  toward  the  clitoris)  propor- 
tionate to  the  dilatability  of  the  canal,  the  friability  of  the  tissues,  and  the 
size  of  the  finger.  I  have  seen  quite  severe  hemorrhage  follow  this  su- 
preme dilatation,  which  was  always  speedily  arrested  by  packing  the  vulvar 
cleft  with  cotton-wool  and  a  tight  T-bandage.  The  index  is  introduced 
nearly  its  whole  length,  and  its  third  joint  and  one-half  of  the  second  then 
project  into  the  bladder,  sufficient  for  palpation  of  that  organ  and  its  sur- 
roundings. 


O^ 


Fig.  79.— Two  of  Simon's  Set  of  tTrethral  Dilators  (Natural  Size),  and  Scale  of  Dilatation. 


If  still  greater  dilatation  is  desired,  a  very  small  cylindrical  speculum 
may  be  introduced  (as  I  have  done)  or  a  bi-  or  trivalve  rectal  speculum 
employed.  But  it  should  be  remembered  that  greater  dilatation  than  the 
size  of  the  index-finger  is  more  than  liable  to  be  followed  by  permanent  in- 
continence. Occasionally,  in  large  stones  or  in  tumors  of  the  bladder  it  is 
necessary  to  open  the  urethral  canal  still  more,  and  it  may  then  be  split 
toward  the  vagina  with  knife  or  scissors  to  greater  or  lesser  length,  only  to 
be  immediately  united  by  suture  after  the  removal  of  the  growth.     The 


DILATATION    OF    THE    URETHRA.  133 

points  of  constriction  of  the  finger  are  at  the  neck  of  the  bladder  and  the 
meatus  ;  chiefly,  I  have  found,  at  the  latter. 

This  operation  has  been  developed  into  a  systematic  procedure  by  the 
late  Professor  Gustav  Simon,  of  Heidelberg,  who  gave  explicit  directions  for 
its  performance  and  demonstrated  its  perfect  innocuousness  (in  his  hands, , 
at  least).  His  method  consists  in  nicking  the  upper  border  of  the  meatus 
with  the  scissors  on  each  side  to  the  depth  of  ^  ctm.,  and  the  lower  border 
once  to  the  depth  of  ^  ctm.  He  then  introduces  his  set  of  hard-rubber 
specula,  guided  by  a  mandrin  with  a  round  button,  one  after  the  other, 
until  the  largest  one  has  been  used.  The  set  consists  of  seven  specula,  vary- 
ing between  f  ctm.  and  2  ctm.  The  largest  is  followed  by  the  index-finger, 
the  corresponding  middle  finger  being  introduced  into  the  vagina  (whei'e- 
by  the  index-finger  is  enabled  to  penetrate  about  one  centimetre  deeper), 
and  the  other  hand  crowding  down  the  bladder.  This  dilatation  is  feasible 
without  the  least  force  in  from  five  to  seven  minutes,  and  laceration  of  the 
urethra  or  vestibule  is  rare,  whereas  Heath  reports  to  have  torn  the  ure- 
thral mucous  membrane  under  the  pubic  arch  in  every  case  of  unaided 
digital  dilatation.  Simon  denies  the  occurrence  of  incontinence  after 
this,  and  even  larger,  dilatation.  Indeed,  he  claims  that  in  the  adult  fe- 
male the  urethra  may  be  dilated  to  the  circumference  of  6.5  to  7  ctm., 
and  in  girls  to  a  circumference  of  4.7  to  6.3  ctm.,  without  incontinence. 
Winckel  corroborates  Simon's  statements  as  to  ease  and  innocuousness  of 
the  dilatation  in  the  above  manner,  but  says  that  in  all  his  seven  cases  the 
incisions  were  torn  deeper,  or  another  tear  occurred  at  the  meatus  ;  the 
pressure  of  the  speculum  arrested  all  hemorrhage.  After  the  largest  dila- 
tation a  forceps  could  be  passed  into  the  bladder  at  the  side  of  the  index, 
which  he  found  impossible  after  simple  digital  distention. 

Since  the  patient  is  generally  anesthetized,  the  rule  is  to  perform  this 
operation  at  her  home  or  in  the  hospital.  But  I  have  several  times  under- 
taken it  in  a  minor  degree,  with  excellent  results,  in  the  out-door  clinic 
and  at  my  office,  with  and  without  chloroform. 

Dangers. — The  chief  danger  resiolting  from  dilatation  of  the  female 
urethra  is  the  possibility  of  permanent  incontinence.  But  this  will  never 
be  observed  after  the  minor  degree  of  dilatation  for  the  little  finger,  and 
but  rarely  after  that  for  the  index. 

The  high  figures  of  Silbermann,  who  collected  forty-eight  cases  of  rapid 
dilatation  with  eight  instances  of  permanent  incontinence,  can  scarcely 
be  considered  a  fair  showing,  since  Simon's  and  Wiuckel's  results  are  en- 
tirely diiTerent.  Winckel  correctly  observes  that  the  operation  in  these 
cases  must  have  been  performed  with  improper  instruments,  and  in  a 
brusque  manner,  not  slowly  and  gradually  with  Simon's  specula,  and  the 
bad  consequences,  therefore,  should  not  be  attributed  to  the  method,  but 
to  its  improper  execution.  Of  recent  writers,  Emmet  is  particularly  em- 
phatic in  warning  against  this  hyper-dilatation,  of  which  he  claims  he  has 
seen  two  proofs  out  of  eleven  cases  in  the  gaping  incontinent  urethrse  of 
women  who  came  to  him  to  the  Woman's  Hospital  for  relief — a  relief 
which,  unfortunately,  is  not  easy  to  give,  as  the  tone  of  the  flabby  canal  is 


134  MINOR    GYNECOLOGICAL    MANIPULATIONS. 

not  restorable,  and  tlie  operation  for  its  constriction  is  a  difficult  one.  In 
contradiction  to  this  warning  voice  is  the  experience  of  Noeggerath,  who 
has  seen  but  two  cases  of  incontinence  out  of  seventy-five  dilatations  ;  and  I 
myself  have,  in  some  fifty  instances,  seen  not  even  temporary  incontinence. 
In  one  case  of  hyper-distention  with  the  index-finger  in  the  bladder  in  a 
young  girl,  urine  was  passed  normally  within  four  hours.  But,  in  view  of 
the  difficulty  of  relieving  permanent  incontinence,  Emmet's  caution  should 
certainly  be  respected,  not  to  practise  the  dilatation  unnecessarily,  rudely, 
or  too  thoroughly.  Whether  Emmet's  dictum,  that  the  advantage  gained 
does  not  compensate  for  the  risk,  is  always  correct,  remains  to  be  seen. 
Certainly  the  very  small  number  of  cases  of  permanent  incontinence  re- 
ported cannot  as  yet  be  considered  as  condemning  the  practice.  I  have 
seen  one  case,  indeed,  in  which  permanent  retention  (which,  it  is  true,  had 
preceded  the  operation,  and  for  which  the  latter  was  performed)  persisted 
after  dilatation  with  the  index-finger.  Another  danger  possibly  following 
dilatation  is  the  production  of  peritonitis.  Of  this,  so  far  as  I  know,  only 
one  case  has  been  reported  (by  Etheridge,  of  Chicago),  in  a  girl  in  whom 
peritonitis  and  fatal  typhoid  followed  a  urethral  dilatation.  The  danger 
of  hemorrhage  from  the  lacerations  pi'oduced  need  scarcely  be  mentioned, 
unless  the  tear  should  extend  so  deeply  into  the  vestibule  toward  the  cli- 
toris as  to  wound  the  large  plexus  of  veins  and  arteries  there  situated,  in 
which  case  the  hemorrhage  might  be  profuse  and  require  to  be  arrested 
by  deep  sutures  and  compression. 

The  recurrence  of  a  chronic  pelvic  perimetritis  or  peritonitis  after  dila- 
tation is  certainly  possible  ;  therefore,  such  conditions,  if  the  least  tender- 
ness on  pressure  or  decided  pain  exists,  would  counterindicate  the  opera- 
tion. 

Other  reaction  than  some  burning  in  the  urethra  and  vulva,  chiefly  on 
micturition,  is  not  usually  noticed.  The  occurrence  of  vesical  catarrh, 
and  of  urethritis  mentioned  by  Noeggerath  and  Winckel,  I  have  not  ob- 
served. Eecognizing  the  possibility  of  such  an  occurrence,  I  have  gener- 
ally advised  the  application  of  cold-water  compresses  to  the  vulva  for 
twenty-four  hours  after  the  dilatation.  Winckel  says  that  the  occurrence 
of  cystitis  after  dilatation  cannot  be  denied,  but  that  irrigation  of  the 
bladder  will  relieve  it  in  a  few  days,  and  that  the  advantages  derived  from 
this  method  of  examination  by  far  exceed  its  dangers. 

The  counter indicatio'ns  to  dilatation  are  such  conditions  as  would  be 
likely  to  produce  permanent  incontinence,  hemorrhage,  or  inflammation, 
viz.:  great  friability  or  brittleness  of  the  tissues,  varicosity  or  edema  of 
the  vestibule,  and  acute  or  subacute  pelvic  or  peritoneal  inflammation. 

III.    INJECTIONS  INTO  THE  BLADDER. 

Under  this  title  are  included  not  only  the  injection  into  the  bladder 
of  medicinal  solutions,  but  also  the  irrigation  or  washing  out  of  the  viscus 
for  purposes  of  cleanliness  or  disinfection. 

The  indications  for  the  introduction  of  fluid   into  the  bladder  are, 


INJECTIONS    INTO    THE    BLADDER.  135 

therefore,  twofold  :  1,  the  washing  out  of  its  cavity,  the  removal  of  decom- 
posing urine  and  mucus,  of  purulent  secretions,  or  inorganic  deposits  from 
the  mine  ;  and  2,  the  injection  of  medicated  fluids  for  the  cure  of  certain 
pathological  conditions.  The  special  indications  for  the  practice  are  al- 
most invariably  the  presence  of  chronic  cystitis  with  its  concomitant  ero- 
sion or  ulceration  of  the  mucous  lining.  As  a  therapeutic  agent  the  sim- 
ple irrigation  of  the  bladder  with  tepid  water,  generally  containing  chloride 
of  sodium  one  drachm  to  the  pint,  frequently  repeated,  wiU  often  suffice 
to  cure  even  obstinate  cases  of  cystitis. 

When  a  patient  complains  of  the  well-known  symptoms  of  cystitis 
(frequent  micturition  always  accompanied  by  vesical  tenesmus  and  scald- 
ing, cloudy,  or  purulent  urine),  and  these  symptoms  have  existed  for  some 
time,  weeks  or  months,  internal  remedies  will  generally  have  been  found 
ineffectual,  and  the  final  resort  to  local  treatment  becomes  imperative. 
The  bladder  is,  then,  usually  first  washed  out  with  the  tepid  salt  solution, 
and,  if  thought  necessary,  its  interior  examined  by  the  endoscope  through 
the  dilated  urethra,  and  direct  application  made  to  any  ulcerated  spots 
which  may  be  discovered.  In  the  large  majority  of  cases  of  chronic  cys- 
titis local  treatment  will  be  found  indispensable  to  the  cure,  or  even  alle- 
viation of  the  disease. 


Fig.  so. — Skene's  Eeflux  Catheter  for  Injecting  the  Bladder. 


Method. — It  may  seem  exceedingly  simple  to  inject  fluids  into  the 
bladder,  when  the  injection-tube  has  once  been  introduced,  and  so  it  is. 
But  there  are  various  precautions  to  be  observed  as  to  the  kind  of  tube, 
force,  and  quantity  of  injection,  which  are  by  no  means  unimj)ortant,  both 
with  regard  to  the  feelings  of  the  patient  and  the  success  of  the  treat- 
ment. 

An  injection  may  be  made  through  the  ordinary  metal  or  hard-rubber 
or  the  elastic  catheter.  But  the  large  size  of  the  eyes  of  the  ordinary 
catheter  permits  folds  of  the  mucous  membrane  of  the  bladder  to  be  sucked 
into  them  when  the  fluid  is  withdrawn,  and  superficial  injury  easily  re- 
sults therefrom.  A  much  preferable  injection-tube  is  one  with  numerous 
small  perforations  within  an  inch  or  more  of  the  blunt  tip.  The  best  in- 
strument is  one  with  a  double  tube  to  enable  the  constant  egTess  of  the 
fluid  while  the  injection  is  going  on.  The  double  catheter  of  Dr.  Skene 
possesses  every  requisite,  the  fluid  entering  through  the  slender  central 
tube  and  escaping  through  the  larger  shell ;  rubber  hose  is  attached  to 
each  nozzle.  The  best  means  of  propelling  the  fluid  is  by  hydrostatic 
pressure  ;  therefore,  a  fountain  syringe  or  irrigator  is  the  instrument  to 
be  preferred.  The  injection  should  be  steady  and  uniform,  not  in  sudden 
jerks.     A  stopcock  in    the  catheter  is   very  convenient  to  regulate  the 


136  MINOR    GYNECOLOGICAL    MANIPULATIONS. 

amount  and  rapidity  of  the  injection  and  escape  of  the  fluid,  A  hard-rub- 
ber catheter  is  preferable  to  a  metal  one,  as  it  is  not  affected  by  acids. 
The  sudden  injection  of  the  fluid  causes  intense  pain  by  subjecting  the 
bladder  to  a  rapid  distention  to  which  it  is  not  accustomed  ;  and  the  quick 
evacuation  of  the  fluid  causes  the  bladder  to  contract  so  rapidly  as  to 
wound  itself  against  the  end  of  the  catheter.  The  regiilation  of  the  flow 
by  the  stopcocks  prevents  either  of  these  occurrences. 

The  necessity  of  avoiding  all  force  in  injecting  the  bladder  has  already 
been  pointed  out.  The  fluid  should  be  allowed  to  flow  in  by  its  own 
weight.  The  quantity  to  be  introduced  at  each  sitting  varies  greatly  with 
the  capability  (not  capacity)  of  the  bladder,  and  that  quality  depends  on 
the  duration  and  severity  of  the  disease,  and  the  consequent  irritability  of 
the  organ.  In  some  cases,  I  have  allowed  a  quart  of  water  to  flow  gently 
into  the  bladder  before  pain  or  desire  to  micturate  was  complained  of  ;  in 
others,  but  a  pint  was  tolerated,  and  in  others  again  but  a  few  ounces.  If 
the  double-current  catheter  is  used  the  water  can  generally  be  allowed  to 
flow  through  the  bladder  until  it  is  perfectly  cleansed,  without  giving  ap- 
preciable pain.  Winckel  proportions  the  amount  to  be  injected  to  the 
age  of  the  patient  and  the  size  of  the  bladder,  |- — |- — 1  litre,  several  times 
daily.  Skene  lays  down  the  following  rule  :  1.  Inject  only  one  ounce  at 
a  time,  repeating  this,  if  necessary,  three  or  four  times  at  the  same  sitting. 
2.  Inject  as  slowly  as  possible,  avoiding  all  sudden  jerking. 

How  the  bladder  can  be  thoroughly  washed  out  by  injecting  only  an 
ounce  of  fluid  each  time  I  cannot  understand,  unless  many  more  separate 
ounces  be  injected  than  Skene  permits  ;  nor  can  I  see  the  necessity  for  such 
excessive  precaution  as  to  the  quantity  so  long  as  a  double  catheter  is  used. 
These  cleansing  injections  or  irrigations  of  the  bladder  should  always  im- 
mediately precede  the  injection  of  a  more  or  less  highly  medicated  fluid. 
In  themselves  the  cleansing  injections  are  an  exceedingly  valuable  thera- 
peutical agent  in  chronic  cystitis.  They  may  be  continued  once  or  several 
times  daily  for  weeks,  and  finally  effect  a  cure.  Pure  water,  however, 
should  not  be  used,  as  it  has  been  found  irritating  to  the  bladder.  The 
addition  of  chloride  of  sodium  one  drachm,  or  chlorate  of  potash  one-half 
drachm,  to  the  pint  makes  the  best  cleansing  fluid  ;  if  there  be  ulceration 
or  suppuration,  a  strained  decoction  of  flaxseed  or  lime-water,  or  better 
still,  a  one  per  cent,  solution  of  carbolic  acid  or  one-tenth  per  cent,  solu- 
tion of  salicylic  acid  may  be  used.  If  the  urine  is  alkaline  or  offensive, 
two  minims  of  dilute  nitro- muriatic  acid  should  be  added  to  the  ounce  of 
water  ;  if  it  is  acid,  as  many  grains  of  bicarbonate  of  soda  to  the  ounce. 
By  injecting  solutions  of  chloride  of  sodium  (4  : 1,000,  increasing  daily  by 
15  grains)  three  times  daily  for  twenty-five  minutes  each  time,  Lemaistre- 
Florian  claims  to  have  cured  chronic  cystitis  in  twenty-one  days.  The 
temperature  of  the  water  should  always  be  from  90°  to  100°  F.  If  these 
cleansing  injections,  one  or  all,  do  not  relieve  the  case,  positively  astringent 
or  caustic  applications  should  be  made.  The  two  great  precautions  to  be 
observed  in  using  these  therapeutic  injections  are  to  inject  only  a  small 
quantity  at  a  time,  from  five  drops  to  one  ounce,  and  never  to  use  solu- 


VAGINAL    INJECTIONS.  137 

tions  strong  enough  to  give  actual  pain.  Winckel  follows  the  irrigation 
with  salicylic  solution  (if  necessary)  by  injecting  a  solution  of  nitrate  of 
silver  of  the  strength  of  1 — 2 — 3  parts  in  500,  or  of  tannin  gr.  v.  to  xv.  to 
3  iv.,  continuing  this  for  weeks.  Braxton  Hicks  uses  for  acute  cystitis  an 
irrigation  of  one  litre  of  acidulated  water  (nitro-muriatic  acid  2  drojDS  to  1 
ounce)  and  then  injects  a  solution  of  morphine  1 — 2  gi'ains  to  the  ounce, 
causing  this  to  be  retained  as  long  as  possible  for  purjoose  of  absorption. 
When  the  acute  symptoms  have  subsided,  solutions  of  tannin,  or  3  to  4 
drops  of  the  tincture  of  the  chloride  of  iron  to  1  ounce  are  injected. 
Skene  recommends  for  pain,  injections  of  chloral  hydrate,  10  to  15  grains 
to  1  ounce  of  water.  As  astringent  and  alterative  injections  Skene 
speaks  of  the  silver-nitrate,  sulphate  of  zinc,  tannic  acid,  and  acetate  of 
lead,  1 — 2  grains  to  the  ounce,  increasing  the  strength,  if  necessary,  but 
not  sufficient  to  give  pain.  Infusion  of  hydrastis  Canadensis  is  also  useful. 
In  obstinate  cases,  Skene  speaks  highly  of  a  strong  solution  of  nitrate  of 
silver,  20  grains  to  the  ounce,  injecting  only  5  to  10  drops  at  a  time.  To 
insure  the  injection  of  no  greater  quantity  an  instillation  tube  of  glass, 
with  small  rubber  bulb  attached,  is  used  by  Skene,  or  a  No.  1  or  2  elastic 
catheter  with  a  hypodermic  syringe  attached  may  be  used,  this  small 
catheter  being  introduced  through  the  larger  one  which  has  first  been 
used  to  wash  out  the  bladder  ;  when  5  to  10  drops  have  been  injected, 
the  small  catheter  is  removed  and  a  little  water  injected  through  the 
larger  tube,  which  dilutes  the  caustic  and  prevents  too  deep  action.  The 
injection  of  normal  urine  in  cystitis  is  deprecated  by  Skene.  Iodoform 
(by  insufflation,  I  suppose)  has  also  been  recommended.  A  solution  of 
iodoform  and  chloral  in  water  (  3  ss.  :  15  grains  to  the  ounce)  would  seem 
to  me  a  very  useful  injection.  If  the  urethra  is  so  tender  as  to  render  the 
introduction  of  the  catheter  difficult  without  anesthesia,  Hicks  and  Skene 
recommend  to  force  the  injection  from  a  larger  syringe  into  the  urethra 
and  bladder  by  inserting  the  point  of  the  syringe  only  part  way  into  the 
urethra  or  simply  holding  it  against  the  meatus  ;  the  stream  is  then  forced 
into  the  bladder,  and  the  necessity  for  anesthesia  may  be  avoided. 

IV.    APPLICATION  OF  MEDICINAL  AGENTS  TO  THE  VAGINA  AND  CERVIX. 

Medicinal  agents  may  be  applied  to  the  mucous  membrane  of  the  va- 
gina, intravaginal  portion  of  the  cervix  and  external  os  uteri,  by  various 
methods,  as  in  solution,  by  vaginal  injections,  through  specula,  and  on 
wads  of  cotton  ;  as  powders,  through  specula,  on  cotton  and  by  insufflation  ; 
as  ointments,  through  specula,  and  by  a  syringe  ;  in  suppositories  and 
capsules,  through  tubes. 

a.   Vaginal  Injections. 

The  application  of  water,  pure  or  medicated,  to  the  walls  of  the  vagina 
and  cervical  portion  of  the  uterus,  in  health  and  disease,  by  means  of 
syringes  of  various  patterns,  has  been  in  use  since  time  immemorial.     The 


138 


JVimOR    GYNECOLOGICAL    MAISTIPULATIONS. 


ease  with  which  such  api^lications  are  made  has  rendered  them  popular  far 
beyond  the  deserts  which  the  merely  temporary  contact  of  the  injection 
fluid  with  the  vaginal  walls  entitles  them  to.  It  is  only  within  recent  years 
that  the  true  value  of  many  of  these  injections  has  been  recognized  to  con- 
sist in  their  thermic  qualities.  The  necessity  for  using  this  method  of  local 
medication,  in  one  form  or  another,  in  the  majority  of  gynecological  cases, 
calls  for  a  detailed  description  of  the  instruments  emj)loyed,  the  constitu- 
tion of  the  fluid,  the  indications  and  utility,  counterindications,  and  dan- 
gers of  vaginal  injections. 


Vaginal  Injection  Apparatuses,  and  their  Use. 

The  number  of  contrivances  for  the  introduction  of  fluids  into  the  va- 
gina is  very  great,  too  great,  indeed,  for  description,  even  if  they  were  all 
practically  useful  and  safe.     I  shall  mention  only  the  few  which  have  stood 

the  test  of  experience,  and  which  answer 
every  purpose  of  utility,  convenience,  and 
economy. 

The  old,  time-honored,  metal  piston- 
syringe  of  the  Europeans  is,  happily,  a 
thing  of  the  past,  with  us,  at  least,  and  is 
mentioned  only  to  be  condemned. 

The  apparatuses  differ  in  construction 
in  one  essential  particular,  viz.,  in  the  pro- 
pulsive agent  by  which  the  fluid  is  forced 
from  the  syringe,  it  being  in  the  one  va- 
riety the  muscular  force  of  the  patient  her- 
self, or  an  attendant ;  in  the  other  variety, 
simple  hydraulic  pressure  ;  in  the  third, 
suction.  Of  the  instruments  operated  by 
the  muscular  force  of  the  patient  or  at- 
tendant only  one  need  be  mentioned,  the 
familiar  Davidson's  syringe,  which  is  in  the 
possession  of  every  woman  in  the  land.  If 
proper  care  is  taken  of  it,  especially  if  it  be 
not  kept  in  too  dry  a  place,  it  will  be  found  very  durable.  Like  all  rubber, 
however,  it  is  liable  to  crack  after  a  time,  and  if  this  accident  hapjoens  to 
the  bulb,  the  syringe  becomes  useless  and  irreparable.  If  only  one  of  the 
valves  shrinks,  it  may  be  replaced  by  a  new  one  at  the  instrument-maker's 
or  druggist's  ;  and  if  the  rubber  tube  wears  through  at  the  junction  with 
bulb  or  attachments,  as  it  often  does,  the  cracked  portion  may  be  cut  off 
and  the  tube  fastened  again  by  tightly  wound  cord,  when  the  syringe  will 
act  as  well  as  ever.  An  objection  to  the  instrument,  as  still  sold,  is  the 
presence  of  a  central  aperture  in  the  vaginal  nozzle,  to  the  danger  of  which 
I  shall  refer  more  at  length  later  on. 

The  one  great  objection  to  the  Davidson,  no  matter  how  excellently  con- 
structed, is  that  the  force  required  to  use  it  for  any  period  of  time  ex- 


FiG.  81. — Davidson's  Vaginal  Syringe. 


YAGIITAL    INJECTION    APPARATUSES,    AND    THEIR    USE.        139 

liausts  the  patient,  or  necessitates  the  aid  of  an  attendant.  To  ob-vdate  this, 
a  siphon  arrangement  has  been  introduced,  the  credit  of  which  has  been 
given  to  Scanzoni.  An  uoijleasant  feature  of  this  contrivance  is  that  the 
air  has  to  be  sucked  out  of,  and  the  water  into,  the  tube  by  applying  the 
mouth  to  the  vaginal  end  ;  this  may  be  avoided  by  allowing  the  water  to 
run  by  gravitation  into  the  tube,  or  laying  bell,  tube  and  all,  with  open 
stopcock,  into  the  water  before  using  it ;  or  the  tube  may  be  supplied  with 
a  rubber  bulb,  by  compressing  which  the  air  is  expelled.  The  flexion  of 
the  rubber  tubing  over  the  border  of  the  vessel  maybe  obviated  by  attach- 
ing a  spout  to  the  vessel,  or  making  the  curve  of  the  tube  of  inflexible 
material,  as  shown  in  the  cut  (Fig.  82).     When  the  stream  has  once  been 


Pig.  82.— Siphon  Vaginal  Syringe. 

directed  through  the  tubing  it  will  continue  to  flow  until  the  vessel  is 
empty.  I  have  mentioned  this  contrivance  because  it  really  is  practical, 
and  may  prove  serviceable  in  emergencies.  But  I  can  hardly  conceive  of 
an  occasion  when  the  much  more  convenient  apparatus,  now  to  be  de- 
scribed, cannot  be  obtained  or  constructed  with  the  same  materials  needed 
for  the  siphon.  The  ordinary  surgical  irrigator  is  certainly  the  jDcrfection 
of  a  vaginal  syringe,  and  combines  convenience,  efiiciency,  and  safety.  It 
may  be  made  as  economical  as  possible  by  vising  a  plain  tin  pail,  ^vith 
ordinary  rubber  tubing  and  glass  nozzle,  or  it  may  be  elegantly  painted 
and  decorated,  and  be  furnished  with  an  unusually  long  tube,  stopcock, 
and  hard-rubber  nozzle.  I  have  had  them  made  by  Mr.  Philip  H.  Schmidt, 
instrument-maker,  of  No.  1311  Broadway,  for  a  number  of  years,  with 
pails  of  different  sizes,  holding  from  one  to  eight  quarts,  at  prices  varying 


140 


MIlSrOE    GYNECOLOGICAL    MANIPULATIONS. 


between  $1.50  and  $4.50,  according  to  size,  length  of  tubing,  and  quality 
of  bard-rubber  work.  For  dispensary  practice  be  has  even  been  able  to 
furnish  them  for  $1.25.  All  these  pails  are  neatly  painted  and  japanned. 
The  nozzle  of  the  cheap  kind  is  glass,  those  of  the  better  varieties  of  hard- 
rubber,  as  well  as  the  stopcock.  The  nozzle  has  no  central  aperture.  The 
tubing  is  attached  to  the  side  of  the  pail  near  the  bottom,  and  not  to  the 
latter,  so  that  the  pail  can  both  be  stood  on  an  elevation  or  suspended 
by  a  pole  near  its  upper  border.  In  recommending  a  syringe  for  thera- 
peutical vaginal  injections  I  have  for  several  years  given  this  irrigator 
decided  preference.  Its  only  objection  is  its  importabilitj' ;  for  cases, 
therefore,  where  the  patient  is  likely  to  need  the  instrument  Avhile  travel- 
ling, I  recommend  the  very  compact  and  portable  fountain  syringe,  which 
consists  of  a  rubber  bag,  holding  from  one  to  four  quarts  (according  to 
number  of  syringe),  with  the  various  attachments  of  hard  rubber  and  glass 
for  vaginal,  rectal,  aural,  nasal,  ophthalmic,  and  other  douches.     Some  of 

these  rubber  bags  are  so  contrived  as 
to  permit  of  their  apertures  being  se- 
curely closed,  when  the  bag  can  be 
used  as  a  hot  or  cold  water,  or  ice 
bag,  at  times  a  great  convenience. 

With  these  few  simple  apparatuses 
my  list  of  vaginal  syringes  closes. 
The  complicated  and  expensive  in- 
struments, with  elegant  Greek  names, 
of  Braun,  Eguisier,  Beigel,  Woodward, 
etc.,  all  act  more  or  less  by  manual 
force,  and  have  no  advantage  whatever 
over  the  Davidson ;  they  are  therefore 
not  worthy  of  recommendation  or  de- 
scription. 

Method  of  Using  Vaginal  Injections. 
— It  is  scarcely  necessary  to  describe 
the  manner  of  using  the  ordinary  vag- 
inal injections  practised  daily,  or  as 
often  as  the  individual  peculiarities 
of  each  case  may  require,  by  every 
woman  who  has  any  regard  for  her  personal  cleanliness.  It  is  for  this 
purpose  that  the  Davidson  syringe  occupies  so  prominent  a  place  in  every 
household,  unless  its  place  be  supplied  by  a  hose  and  perforated  tube  at- 
tached to  the  water-closet  or  the  bath-tub  faucets  ;  or  a  real  French  bidet 
with  ascending  vaginal  tube  and  single  or  double  water  compartment  is 
used.  The  latter  contrivance  is  certainly  very  convenient,  since  its  height 
enables  the  lady  to  sit  comfortably  on  it  as  she  would  on  a  chair,  and  the 
fatiguing  crouching  on  the  ordinary  chamber-vessel,  and  attending  crowd- 
ing down  the  uterus,  is  thereby  avoided.  The  vaginal  tube  of  the  bidet  may 
be  connected  with  the  wash-bowl  faucets,  by  a  double  tube,  so  as  to  allow 
the  water  from  the  hot  and  cold  faucets  to  mingle  and  be  resulated  at  will. 


Fig.  83. — Vaginal  Irrigator,  with  Tube. 


VAGINAL    INJECTION    APPARATUSES,    AND    THEIR    USE.        141 

For  ordinary  cleansing  purposes,  the  erect,  sitting,  or  crouching  posi- 
tion is  admissible,  but  not  advisable.  But  for  the  administration  of  tliera- 
peutic  vaginal  injections  the  dorsal  recumbent  position  with  elevated  hips 
is  the  only  one  to  be  recommended  or  allowed.  Whatever  the  injec- 
tions may  be  used  for,  whether  as  astringents,  hemostatics  or  absorbents, 
they  can  only  exert  their  full  benefit  when  the  patient  is  lying  down. 
In  the  erect  or  crouching  position  (esioecially  the  latter),  the  abdominal 
and  pelvic  viscera  are  naturally  crowded  down,  the  vagina  is  shortened, 
and  the  cervix  uteri  forced  toward  the  vaginal  orifice.  Obviously  the 
injection  fluid  will  then  fail  to  reach  every  poi'tion  of  the  rugous  and  col- 
lapsed vagina,  the  lips  of  the  external  os  will  be  separated,  and  the  fluid 
given  free  admission  to  the  uterine  cavity,  and  any  displacement  of  the 
uterus  and  ovaries,  and  accompanying  hyperemia  (for  the  reduction  of 
which  latter  the  injections  may  have  been  ordered)  will  be  increased. 
Besides,  the  immediate  escape  of  the  fluid  to  a  great  extent  invalidates  the 
benefit  to  be  expected  from  a  longer  contact  between  it  and  the  vaginal 
surface. 

Therefore,  whether  the  apparatus  used  be  the  Davidson  syiinge,  with 
its  interrupted  current,  or  the  steady  stream  from  the  irrigator,  the  pa- 
tient should  occupy  the  recumbent  position  on  her  back,  with  elevated 
hips ;  in  this  position  the  abdominal  viscera  gravitate  toward  the  dia- 
phragm, the  abnormally  stretched  uterine  Hgaments  become  relaxed,  and 
the  vagina  is  readily  distended  by  the  injected  fluid,  a  portion  of  which  will 
remain  in  the  vaginal  pouch,  and  in  contact  with  the  cervix  until  the  pa- 
tient resumes  the  erect  position.  The  imperative  necessity  for  the  adop- 
tion of  this  dorsal  position  during  all  species  of  vaginal  injections  has  not 
been  clearly  recognized  and  sufficiently  insisted  upon  until  quite  recently, 
and  it  is  chiefly  to  Emmet  that  the  credit  is  due  for  its  j)opularization,  so 
far  as  the  systematic  injection  of  hot  water  is  concerned.  Really  popular, 
it  is  safe  to  say,  the  position  has  not  become  even  yet ;  and  I  am  confident 
of  not  overstating  the  fact  when  I  say  that  the  large  majority  of  general 
practitioners  are  still  in  the  habit  of  recommending  vaginal  injections, 
medicated  or.  not,  without  the  slightest  direction  either  to  the  manner  or 
position  in  which  they  should  be  used,  or  the  quantity  to  be  injected. 
The  almost  uniform  result  is  that  the  patient  hastens  over  the  disagree- 
able treatment  as  much  as  possible,  and  uses  the  injection  in  the  habitual 
crouching  or  erect  position,  taking  as  little  fluid,  and  cutting  the  whole 
process  as  short  as  possible,  and  consequently  deriving  but  little  benefit. 
Physicians  should,  therefore,  be  careful  to  impress  upon  their  patients  not 
only  the  exact  proportions  and  the  quantity  of  the  solution  to  be  injected, 
but  also  the  temperature  of  the  fluid,  the  force  and  duration  of  each  in- 
jection, the  manner  of  introducing  the  tube,  the  position  to  be  occupied 
during  the  process,  and  the  length  of  time  this  treatment  is  to  be  con- 
tinued. Attention  to  all  these  details  will  insure  the  best  results,  and  the 
avoidance  of  accidents  and  disappointment. 

The  disadvantage  of  the  recumbent  position  during  vaginal  irrigation 
is  the  difficulty  of  combining  comfort  and  a  proper  receptacle  for  the  in- 


142  MIjSTOE    gynecological    MANIPULATION'S. 

jection  fluid  as  it  leaves  the  vagina.  If  the  Davidson  syringe  witli  its 
short  tubes  is  used,  another  difficulty  is  added,  viz. :  the  placing  of  the  ves- 
sel holding  the  injection  fluid  conveniently  to  the  vulva  and  hand  of  the 
patient.  This  difficulty  may  be  obviated  by  the  assistance  of  an  attend- 
ant, but  it  is  not  always  convenient  or  possible  to  secure  such  a  one.  Be- 
sides, in  both  systems  of  syringes,  the  injection  of  a  large  quantity  of  fluid 
requires  the  emptying  of  the  receptacle  once  or  oftener,  a  duty  also  de- 
volving on  an  attendant.  But  this  place  of  an  attendant  can  be  sujDplied 
by  any  one,  even  by  a  young  girl,  and  there  will  rarely  be  a  family  in 
which  such  assistance  cannot  be  obtained,  if  necessary.  If  a  large-sized 
irrigator,  and  a  chamber  vessel  or  large  bedpan  be  used,  or  one  of  the  de- 
vices now  to  be  described  is  employed,  the  services  of  an  attendant  can 
usually  be  dispensed  with,  the  patient  herself  emptying  the  receptacle 
when  the  injection  is  completed. 

To  overcome  this  difficulty  various  plans  have  been  suggested  and 
contrivances  devised.  I  have  found  an  ordinary  large  chamber- vessel 
placed  under  the  nates  of  the  patient,  her  back  and  head  being  properly 
supiDorted  by  pillows,  to  answer  admirably.  Of  coui'se,  a  little  ingenuity 
is  required  to  place  the  vessel  so  that  it  does  not  sink  obliquely  into  the 
mattress,  and  allow  the  water  to  escape  on  one  side  ;  and  also  to  j^lace  the 
pillows  comfortably.  A  shovel  bedpan,  as  a  rule,  does  not  answer  well, 
because  its  bevelled  edge  is  Hable  to  sink  into  the  mattress,  and  its  ca- 
pacity is  too  small.  The  old-fashioned  round  bedpans  are  greatly  jDref era- 
ble  in  this  respect.  Dr.  Emmet  has  the  round  bedpans  made  of  copper, 
with  a  small  outlet-pipe,  over  which  a  rubber  tube  is  slipped  to  conduct 
the  water  from  the  pan.  If  the  bed  or  couch  is  very  soft,  a  board  or  hard 
cushion  should  be  placed  under  the  receptacle  on  which  the  patient  lies. 
A  round  rubber  air-cushion,  fully  inflated,  with  closed  central  hollow,  will 
do  very  well,  the  water  being  caught  in  the  large  central  opening  ;  if  an 
escape-tube  at  the  side  is  attached,  as  I  have  seen  them,  every  requisite  is 
supplied.  A  very  simj)le  and  efficient  substitute  for  a  receptacle  is  fur- 
nished by  a  large  rubber  cloth  properly  arranged  ;  this  is  hung  over  the 
edge  of  the  bed,  the  patient  is  placed  on  it  with  her  hips  close  to  the  edge, 
and  each  foot  on  a  chair  close  to  the  bed  ;  the  mattress  at  the  edge  is 
pressed  do\vnward,  and  a  crease  leading  over  the  edge  made  in  the  rubber 
sheet  ;  down  this,  water  escaping  from  the  vagina  flows  into  a  bucket  on 
the  floor.  Of  course,  again,  care  must  be  taken  not  to  let  other  creases 
run  up  on  the  bed,  and  the  vulva  must  be  at  the  very  extreme  edge  of 
the  bed,  or  else  accidents  will  happen,  and  patients  will  be  disgusted 
with  the  method  when  they  have  only  their  own  awkwardness  to  blame. 
Or,  two  chau-s  may  be  placed  close  together,  and  the  patient  lie  on  them 
so  as  to  bring  the  vulva  directly  over  the  space  between  them,  her  legs 
resting  on  a  third  chair,  and  the  upper  portion  of  her  body  lying  on  the 
side  of  the  bed.  The  water  will  then  trickle  from  the  vagina  into  a  pan 
placed  between  the  two  chairs. 

Noeggerath  and  Lord  have  employed  the  ordinary  bedpan  with  an 
escape-pipe  attached.     I  have  had  made  a  very  convenient,  and  but  mod- 


VAGIIS"AL    INJECTIOIS-    APPARATUSES,    AND    THEIR    USE.       143 

erately  expensive  flat  round  pan,  of  zinc,  which  with  its  supplying  and  re- 
ceiving vessel  is  shown  in  the  accompanying  diagram.  With  these  devices 
it  is  important  that  the  surface  on  which  the  vessel  rests  should  be  mod- 
erately hard  and  unyielding.  If  these  methods  do  not  answer,  the  injec- 
tions, being  generally  given  night  and  morning,  may  be  used  in  a  long 
bath-tub,  the  patient's  hips  being  raised  on  a  inibber  cushion.  Various 
gynecologists  have  endeavored  to  dispense  with  all  these  paraphernalia  and 
difficulties  by  constructing  injection-tubes  with  broad  rubber  cups  or 
plates  to  fit  over  the  vulva,  and  effei'ent  tubes  to  conduct  the  water  fi-om 
the  vagina.  Those  of  Mathieu-Kisch,  Frank 
P.  Foster,  and  Scarff  are  the  only  ones  known 
to  me.  That  of  Foster,  having  the  largest  and 
best  fitting  cup,  appears  to  me  the  most  useful. 
I  have  not  used  it,  but  Dr.  Emmet  testifies  to 
the  tight  fit  of  the  cup  and  the  entire  absence 
of  escajDC  of  fluid  except  through  the  efferent 
tube.  Another  advantage  of  these  instrunaents 
with  escape-tubes  is  the  protection  of  the  vulva 
and  perineum  from  the  injection  fluid  which, 
as  is  chiefly  the  case  when  injections  of  hot 
water  are  used,  may  at  first,  until  the  parts 
become  toughened,  cause  considerable  pain 
when  it  escapes.  When  such  hot  injections 
are  used  it  is  always  advisable  to  protect  the  ^^<^-  84.— Munde's  n-rigator-Pan. 
perineum  by  a  large  sponge  or  napkin  wet  in  cooler  water.  It  should  be 
remembered  that  water  of  a  temperature  which  is  pei-fectly  comfortable  to 
the  comparatively  insensitive  vaginal  mucous  membrane  becomes  scalding 
when  it  touches  the  highly  innexwated  external  skin. 

The  quantity  of  fluid  to  be  injected  at  each  sitting  varies  -odth  the 
constitution  of  the  fluid  and  the  object  in  view.  If  merely  cleansing  in- 
jections are  intended,  a  pint  or  quart  will  siiffice.  If  disinfection  is  de- 
sired besides,  the  quantity  should  be  larger  and  the  flow  should  continue 
until  the  efflux  is  free  fi-om  all  impurities  or  odor.  If  an  astringent  eflect 
is  designed,  a  smaller  quantity,  a  pint  or  less,  will  suffice,  but  it  should 
be  retained  for  some  little  time,  five  to  fifteen  minutes.  If  the  injection 
is  to  act  as  a  hemostatic,  if  it  be  a  medicated  fluid,  only  a  small  quantity 
is  needed  and  it  should  be  retained  for  fifteen  minutes  or  longer  ;  if  it  be 
designed  to  act  through  its  thei'mic  qualities,  the  quantity  should  be  large, 
the  temperature — hot  or  cold — as  high  or  low  as  can  be  borne,  and  the 
force  considerable.  If  a  stimulant  or  absorbing  effect  be  intended,  the 
quantity  of  fluid — always  hot  now — should  be  still  larger,  the  force  and  the 
length  of  time  of  each  sitting  even  greater.  When  a  tonic  influence  is  in- 
tended, the  quantity  of  fluids  should  not  be  so  large  nor  the  temperature 
so  high,  but  the  force  may  still  be  considerable. 

In  accordance  with  the  force  desii'ed  the  in-igator  is  to  be  elevated  or 
depressed. 

The  frequency  with  which  vaginal  injections  should  be  given  varies 


144 


MINOR    GYJ^ECOLOGICAL    MANIPULATIONS. 


from  once  to  three  or  four  times  or  more  a  daj^  according  to  the  strength 
of  the  fluid  and  the  effect  desired. 

It  is  evident  that  no  special  rules  can  be  given  in  these  general  terms 
either  for  the  exact  quantity  of  the  injection  fluid,  the  force  of  the  in- 
jection, or  the  length  of  each  sitting  ;  all  these  must  be  determined  by 
the  peculiarities  of  each  individual  case  and  by  the  experience  of  the  prac- 
titioner. 

I  have  already  stated  that  every  vaginal  injection,  with  the  sole  excep- 
tion of  the  ordinary  cleansing  injection  commonly  used  during  health, 
should  be  taken  in  the  dorsal  recumbent  position.  This  rule  is  especially 
applicable  to  the  injections  of  water  at  a  high  temperature,  the  so-called 
"vaginal  baths"  of  the  New  York  Woman's  Hospital,  introduced  into 
gynecological  practice  as  a  systematic  therapeutic  agent  by  Thomas  Addis 
Emmet  some  twenty  years  ago  or  more.     Although  he  has  repeatedly  de- 


FiG.  85. — Foster's  Apparatus  for  Vaginal  Irrigation. 

scribed  the  method  and  therapeutic  rationale  of  these  copious,  hot  water 
injections,  and  their  method  and  value  are  familiar  to  all  the  pupils  of  Em- 
met and  the  institution  in  which  he  has  ofiiciated  and  taught  so  ably  for 
many  years,  and  to  many  specialists,  neither  the  details  nor  the  rationale 
of  the  method  have  been  properly  understood  by  the  majority  of  the  pro- 
fession. This  was  certainly'-  the  case  until  the  publication  of  Emmet's  book 
less  than  three  years  ago  ;  since  then,  I  daresay,  his  peculiar  methods  have 
been  studied  by  many  wiio  formerly  had  scarcely  a  suspicion  of  the  details 
of  modern  gynecological  practice.  Notwithstanding,  as  this  treatise  is 
written  for  the  young  practitioner  and  embryo  gynecologist,  I  will  run  the 
risk  of  being  diffuse,  and  again  point  out  the  cardinal  differences  between 
the  old  methods  of  giving  vaginal  injections  and  the  new  system  as  em- 
ployed chiefly  for  the  introduction  of  hot  water  into  the  vagina.  Formerly 
the  injections  were  taken  in  the  erect,  sitting,  or  crouching  position,  the 
temperature  and  quantity  of  injection-fluid  were  not  at  all  or  indistinctly 
prescribed,  and  the  length  of  each  sitting  not  specified.  The  disadvantages 
of  injections  thus  administered  have  already  been  enumerated. 


VAGINAL    INJECTION-    APPAEATUSES,    AND    THEIR    USE.        145 


The  present  method  is  as  follows  :  The  patient  occupies  the  dorsal  re- 
cumbent position,  with  elevated  hips  and  depressed  shoulders,  lying  on 
one  of  the  various  contrivances  described  above  ;  the  outlet  of  the  vagina 
should  be  higher  than  its  vault,  so  that  the  canal  is  always  distended  by  the 
fluid.  The  water  should  be  as  hot  as  can  be  borne,  beginning  with  100° 
to  105°  F.,  and  increasing  a  degree  or  more  daily  until  115°  to  120°  F,  is 
reached.  It  is  not  necessary  to  exceed  the  latter  temperature.  The  vessel 
containing  the  hot  water  should  be  suspended  at  least  two  feet  above  the 
couch  of  the  patient,  higher  if  more  force  is  desired.  The  water  is  al- 
lowed to  escape  from  the  nozzle  before  introducing  it,  so  as  to  expel  the 
air.  The  nozzle  may  be  dipped  in  cool  water  for  a  moment,  if  the  injec- 
tion-fluid be  very  hot,  before  passing  it  through  the  sensitive  vulvar  open- 
ing into  the  vagina.  The  vaginal  tube  should  be  passed  along  the  posterior 
wall  of  the  vagina  into  the  posterior  pouch ;  if  this  is  not  done,  its  point 
may  be  introduced  directly  into  the  external  os  and  the  uterine  cavity  in- 
jected, thus  giving  rise  to  severe  or 
dangerous  uterine  colic.  Ail  this 
can  be  done  by  a  patient  of  average 
intelligence  and  determination  ;  a 
nurse,  of  course,  is  a  help,  but  not  a 
necessity.  A  hot  vaginal  bath,  when 
given  as  a  therapeutical  measure, 
should  be  taken  at  least  twice  a  day, 
aijd  a  quantity  of  water  used  each 
time,  which  will  require  at  least 
twenty  minutes  to  escape  from  the 
irrigator  ;  the  latter  will  thus  require 
refilling  several  times.  These  injec- 
tions, in  order  to  prove  of  benefit, 
should  be  continued  regularly,  with 
the  exception  of  the  menstrual  pe- 
riods, for  months,  and  even  several 
years. 

I  have  had  constructed  an  irriga- 
tor, with  a  thick  glass  thermometer 
inserted  in  a  slot  in  the  side,  open  inside  and  outside,  so  that  the  tempera- 
ture of  the  douche  can  be  controlled  at  a  glance  by  the  patient  or  nurse 
(Fig.  86). 

The  influence  of  gravitation  and  the  relief  of  venous  congestion  aimed 
at  by  the  dorsal  position  with  elevated  hips  is  attained  to  a  still  greater 
degree  in  the  knee-chest  position.  This  position  may,  therefore,  be  adopted 
in  aggravated  cases  when  the  fullest  possible  effect  from  the  hot  injections 
is  desired.  Its  disadvantages  are  three-fold,  viz.  :  the  impossibility  of  pa- 
tients, particularly  such  as  may  most  require  this  treatment,  remaining 
sufficiently  long  in  the  uncomfortable  position,  the  difficulty  of  keeping  the 
patient  dry,  and  the  scalding  of  the  exceedingly  sensitive  vestibule  and 
clitoris  by  the  escaping  hot  water.  The  first  objection  is  irremediable. 
10 


Fig.  86. — Munde's  Irrigator  with  Thermometer. 


146  MINOR    GYNECOLOGICAL    MANIPULATIONS.  ' 

The  second  and  third  can  be  met  by  using  a  funnel-shaped  apparatus  with 
rubber-tube  attached  to  the  smaller  end,  or  the  double-current  contrivance 
of  Dr.  Foster.  In  cases  of  obstinate  leucorrhea,  particularly  of  infectious 
character,  this  same  knee-chest  position  is  admirably  adapted  for  the 
introduction  by  means  of  a  syringe  into  the  vagina  of  medicated  fluids, 
w^hich,  in  consequence  of  the  distention  of  the  vagina  in  this  position, 
reach  every  fold  and  nook  of  the  canal,  and,  being  retained  each  time  as 
long  as  the  patient  can  bear  the  posture,  exert  a  more  permanent  beneficial 
influence. 

The  chief  points  to  be  impressed  on  the  patients  in  using  these  hot 
vaginal  injections  are,  therefore  :  1.  Eecumbent,  or  knee-chest  position. 
2.  Water  as  hot  as  can  be  borne  without  distr'ess.  3.  Duration  of  each 
sitting  not  less  than  twenty  minutes.  4.  At  least  two  sittings  a  day.  5. 
Introduction  of  the  vaginal  tube  along  the  posterior  waU.  6.  Perseverance 
for  months  and  years. 

In  his  book  Dr.  Emmet  expresses  decided  jDreference  for  the  inter- 
rupted stream  of  a  Davidson  syringe  over  the  constant  current  of  the 
irrigator  in  all  cases  where  he  desires  the  stimulant  and  absorbent  effects 
of  the  hot  douche.  That  he  is  right  in  this  view  will  not  be  disj)uted. 
But  the  excellent  results  which  he  justly  claims  for  the  hot  douche  in  the 
Woman's  Hospital  patients  have  been  obtained  by  the  hot  constant  cur- 
rent, the  irrigator  being  the  apparatus  used  in  the  hospital.  Very  few 
patients  will  be  found  strong  and  willing  enough  to  compress  the  bulb  of 
a  Davidson  syringe  for  twenty  minutes,  and  even  the  nurse  is  not  to  be 
envied  to  whom  this  task  is  delegated.  Any  one  who  has  worked  the 
air-bulb  of  a  Paquelin  thermo-cautery  during  an  operation  will  appreciate 
the  correctness  of  this  observation.  Only  in  hospitals  and  with  wealthy 
patients,  with  nurses  at  their  disposal,  will  it  be  possible  to  insist  upon 
the  interrupted  stream.  I  am  confident  that  the  constant  current,  if 
administered  by  the  rules  above  given,  will  answer  every  reasonable  ex- 
pectation and  meet  with  the  hearty  concurrence  of  the  patients.  Nu- 
merous cases  of  pelvic  cellulitis,  ovaritis,  and  areolar  hyperplasia  have 
proved  to  me,  beyond  the  shadow  of  a  doubt,  the  value  of  the  hot  con- 
stant current. 

Before  closing  this  section  I  wish  to  refer  again  to  the  construction 
of  the  vaginal  tube  in  all  forms  of  syringes.  All  tubes  should  be  of  hard 
rubber.  The  bulbous  expansion  of  the  tube  should  not  be  so  large  as  to 
be  difiicult  of  introduction  in  virgins.  The  tube  need  not  be  curved.  It 
should  be  sufiicieutly  long  to  reach  to  the  posterior  vaginal  pouch,  about 
five  inches.  But  above  all,  its  olive-shaped  tip  should  not  possess  a  cen- 
tral perforation.  The  holes  should  all  surround  the  tip,  but  the  centre 
be  imperforate.  If  the  tube  already  in  possession  of  the  patient  have 
this  central  aperture,  it  should  be  plugged  with  wood  ;  or,  if  the  tube  be 
of  the  old  variety  and  of  malleable  metal,  it  should  be  hammered  up.  That 
this  anxiety  on  my  part,  concerning  this  central  aperture,  is  not  fancied 
has  repeatedly  been  demonstrated  of  recent  years  to  myself  and  others. 

Many  women  possess  lacerated  cex'vices,  or  suffer  from  endotrachelitis 


VAGINAL    INJECTION    APPARATUSES,    AND    THEIR    USE.       147 

and  the  external  os  gapes,  or  the  uterus  is  low  in  the  pelvis,  and  its  ex- 
ternal OS  points  directly  in  the  axis  of  the  vaginal  outlet.  How^  easy  is  it 
for  a  woman  to  pass  the  point  of  the  tube  directly  into  the  external  os 
and  force  a  stream  of  water  or  medicated  fluid  (particularly  from  a  David- 
son or  other  interrupted  current  syringe)  straight  into  the  uterine  cavity, 
and  perhaps  through  the  Fallopian  tubes.  The  danger  from  shock  of  for- 
cibly distending  the  unimpregnated  uterine  cavity  by  sudden  injection  of 
fluid  has  deterred  the  majority  of  gynecologists  from  using  therapeutic 
intra-uterine  injections,  irrespective  of  the  possibility  of  the  fluid's  passing 
through  the  tubes  and  exciting  peritonitis.  The  nature  of  the  fluid  is  not 
absolutely  material,  for  even  water  or  glycerine  has  produced  dangerous 
symptoms.  It  is  therefore  evidently  of  the  highest  importance  to  avoid 
this  accident,  which  may  occur  at  any  injection  with  an  improper  tube. 
Until  within  a  few  years  I  had  quite  a  number  of  cases  of  uterine  coHc, 
diffuse  abdominal  pain  and  tendei'ness,  febrile  reaction,  reported  to  me  by 
patients  for  whom  I  had  directed  simple  vaginal  injections  of  mild  astrin- 
gent solutions  and  even  plain  water.  The  symptoms  came  on  immediately 
after  or  during  the  injection.  I  noticed  that  these  cases  appeared  to  be 
chiefly  such  as  had  lacerated,  gaping  cervices,  and  the  true  solution  of  the 
mystery  occurred  to  me.  Since  using  nozzles  without  a  central  aperture, 
I  have  had  no  more  accidents  referable  to  involuntary  intra-uterine  injec- 
tions. Since  1875,  Drs.  More  Madden,  of  Dublin,  Paddock,  of  Nashville, 
and  Simmons,  of  Yokohama,  have  reported  cases  of  severe  collapse,  and 
even  peritonitis,  following  simple  vaginal  injections  ;  and  Dr.  Petit,  of 
Little  Rock,  Ark.,  relates  three  cases  of  death  undoubtedly  due  to  the 
same  cause.  Spath,  of  Vienna,  also  had  a  fatal  result  after  the  injection  of 
a  solution  of  acetate  of  lead  ;  the  post-mortem  revealed  the  sulphide  of 
lead  on  the  ovaries. 

The  instrument-makers  are  difficult  to  move  from  their  beaten  path. 
It  was  only  after  repeated  directions  that  I  succeeded  in  inducing  mine 
to  conform  with  my  wishes  regarding  the  closure  of  the  central  aperttu'e. 
Physicians  will  do  well  to  insist  that  the  tip  of  every  vaginal  tube  fur- 
nished them  or  their  patients  shall  possess  the  regulation  shape  of  an  olive, 
or  at  least  a  bulbous  expansion  with  a  certain  number  of  openings  around 
the  crown  of  the  bulb,  but  none  at  the  very  tip.  Slender,  pointed  vaginal 
tubes  with  central  aperture  should  be  utterly  condemned. 

Composition  of  Vaginal  Injections. — The  injections  used  for  cleansing 
may  consist  of  simple  tej^id  water  or  of  suds  of  castile  or  tar  or  glycerine 
soap,  or  a  weak  solution  of  carbolic  acid  (1 :  200),  j^ermanganate  of  pot- 
ash (only  enough  to  give  the  water  a  light  pink  color)  ;  or  bicarbonate  or 
borate  of  soda  may  be  used,  if  the  vaginal  secretion  is  very  acid.  Injec- 
tions of  cold  water  should  not  be  used  habitually,  unless  as  a  therapeutic 
agent  under  medical  direction,  in  relaxed  and  enfeebled  conditions  of  the 
pelvic  organs. 

Injections  for  therapeutic  purposes  consist  either  of  pure  water,  in 
which  case  they  are  either  hot  or  cold,  and  act  wholly  by  their  thermic 
properties,  and  by  the  shock  exerted  by  the  force  which  propels  them  ;  or 


148  MIl^OR    GYNECOLOGICAL    MANIPULATIOlSrS. 

of  solutions  of  medicinal  agents.  The  thermic  influence  of  vaginal  injec- 
tions decidedly  exceeds  that  of  the  ordinary  mild  medicated  injections, 
the  mildness  of  which  is  regulated  to  a  great  extent  by  their  necessary 
contact  with  the  external  genitals  as  they  escape.  A  vastly  greater  effect 
is  exerted  by  a  very  hot  or  a  very  cold  injection  than  could  result  from 
any  medicated  solution  of  justifiable  strength.  The  exact  temperature  of 
the  water  used  for  injection  is  a  matter  of  importance.  Between  35°  and 
55°  F.  the  water  may  be  considered  cold,  between  55°  and  70°  cool,  be- 
tween 70°  and  85°  tepid,  between  85°  and  100°  warm,  and  above  100°  hot. 
When  directing  the  temperature  of  a  vaginal  injection  it  is  well  to  specify 
the  exact  degree  at  which  the  injection  should  be  begun,  and  the  ratio  at 
which  the  temperature  is  to  be  increased  or  diminished. 

Cold  vaginal  injections,  formerly  in  universal  use,  are  now  but  rarely 
employed,  except  in  cases  of  postpartum  and  other  hemorrhage.  When 
I  say  that  they  are  but  rarely  employed,  I  mean  by  direction  of  the  gyne- 
cologist. Without  such  direction  I  am  sure  they  are  employed  in  many 
instances  where  they  should  not  be,  and  whei-e  they  do  either  no  good  or 
actual  harm.  Thus,  in  congestions  and  inflammations  of  the  pelvic  organs, 
cold  water  injections  are  doubtless  still  recommended  by  physicians  of  the 
old  school,  to  whom  the  more  rational  teachings  of  the  present  day  are  un- 
known or  unpalatable. 

Formerly,  cold  and  ice  water  was  employed  in  all  cases  where  contrac- 
tion was  desired,  and  tepid  water  injections  were  then  habitually  recom- 
mended. Hot  water  was  entirely  disregarded  as  a  therapeutic  agent  in 
uterine  disease.  It  is  only  within  a  few  years  that  the  profession  have 
gradually  become  aroused  to  the  value  of  this  agent ;  but  once  aroused, 
the  revulsion  in  this  particular  has  been  marked,  especially  in  this  country. 
While  the  Germans  and  English  have  recognized  the  value  of  hot  water 
as  a  styptic,  chiefly  in  postpartum  hemorrhage,  the  American  gynecologists 
have  introduced  it  into  their  special  practice.  Where  formerly  cold  was 
employed,  heat  is  now  used  and  attains  the  same  object  with  more  cer- 
tainty and  permanence,  and  with  less  discomfort  to  the  patient.  The  ra- 
tional and  therapeutic  application  of  hot  water,  as  now  employed  in  uterine 
disease,  will  be  considered  under  the  head  of  Indications. 

Tepid  injections,  so  generally  recommended  and  inadvertently  used 
by  the  patients  in  place  of  the  hot  injections  directed,  have  no  positive 
therapeutic  effect  whatever  ;  they  act  merely  as  a  warm  bath  does  on  the 
body,  by  cleansing  and  soothing  the  surface,  and  removing  the  secretions. 

The  list  and  variety  of  medicated  vaginal  injections  is  large.  The 
medicinal  agents  employed  in  this  manner  in  solution  belong  either  to  the 
class  of  disinfectants,  astringents,  alteratives  (promoters  of  absorption) 
emollients,  narcotics. 

The  disinfectants  in  ordinary  use  and  their  proportions  are  :  corrosive 
subhmate  (1  to  1,000  or  2,000),  carbohc  acid  (^—1  to  100),  thymol  (1  to 
1,000),  permanganate  of  potash  (1  to  1,000),  liquor  sodse  chlorinatse,  La- 
barraque's  solution  (1  to  2),  chlorine  water  (1  to  2),  salicylic  acid  (1  to 
1,000  hot  water),  sulphite  of  soda  (1  to  200). 


VAGIlSrAL    INJECTION    APPAEATUSES,    AND    THEIR    USE.       149 

The  formula  used  in  the  Maternity  Hospital,  New  York,  for  a  disin- 
fectant solution  of  thymol,  is  as  follows  : 

]J  •    Thymol 3  j. 

Glycerinee 3  j. 

Alcoholis I  viij. 

Aquse,  q.  s ad  Oj. 

M.    Sig.— Sol.  thymol,  3  j-  to  Oj. 

Of  this  sufficient  is  poured  into  warm  water  to  give  it  a  distinct  odor 
of  thymol,  and  then  injected.  This  is  an  excellent  and  agreeable  addition 
to  water  for  washing  the  hands  after  examination,  and  in  bo  wise  affects 
the  skin,  as  carboHc  acid  solutions  do. 

There  is  comparatively  little  difference  in  the  disinfectant  properties  of 
these  various'  preparations  ;  if  used  in  sufficient  quantity  and  strength  they 
all  answer  their  purjDose.  Formerly  the  most  popular  for  vaginal  injec- 
tions were  the  carbolic  acid,  thymol,  and  permanganate  of  potash  solu- 
tions ;  certain  gynecologists  prefer  the  chlorine  w^ater,  and  others  the 
salicylic,  such  preference  being  usually  merely  the  result  of  habit  or  a 
matter  of  taste.  One  point  of  preference  of  the  permanganate  of  potash 
solution  is  its  oxygenation  of  all  dead  substance  and  its  change  from  violet 
red  to  a  brown  color  thereby  ;  when  all  effete  matter  is  removed,  the  fluid 
escapes  in  its  original  violet  color.  The  sulphite  of  soda  solution  is 
specially  adapted  to  cases  where  the  presence  of  vegetable  fungi  on  the 
vaginal  mucous  membrane  is  the  cause  or  maintainer  of  a  secretion. 
The  compound  sold  as  bromo-chloralum  is  also  an  excellent  disinfectant 
and  astringent,  being  used  for  the  former  purpose  in  the  jDroiDortion  of  1 
to  50  or  100,  for  the  latter  1  to  10  or  20  parts  of  water.  Another  com- 
bination of  various  chloi'ides  (zinc,  magnesium,  potash,  etc.),  known  as 
Piatt's  chlorides,  "has  been  used  by  me  for  several  years  for  the  same 
purposes,  and  is  a  very  powerful  agent.  As  a  disinfectant  I  use  half  a 
pint  of  the  solution  to  one  gallon  of  water,  perfuming  it  if  it  is  to  be  used 
in  the  water-closet  or  in  vessels,  with  an  ounce  of  the  spirit  of  sassafras. 
As  an  astringent  injection  1  part  to  50,  as  a  caustic  equal  parts  of  the  solu- 
tion and  water  are  about  the  proper  proportions.  Undoubtedly  the  most 
efficient  disinfectant,  because  the  most  powerful  germicide,  is  the  corrosive 
sublimate.  The  danger  of  mercurial  toxemia  should,  however,  always  be 
borne  in  mind  when  using  it.  In  all  disinfectant  applications  it  is  im- 
portant that  the  stream  be  continued  until  it  returns  perfectly  free  of 
odor  and  debris.  The  irrigator,  therefore,  is  the  most  convenient  and 
practical  apparatus  for  their  administration. 

One  of  the  best  astringents  is  cold,  or  rather  ice  water.  Its  effects  can 
be  attained  either  through  the  strong  general  or  local  shock  when  its  ap- 
plication is  but  momentary,  or  through  the  jpermaneut  contraction  of  the 
blood-vessels  when  the  contact  is  continuous.  The  objections  to  its  use  as 
an  astringent  are  the  unpleasant  shock  and  chill  it  gives  to  the  patient, 
and  the  necessity  for  its  prolonged  use,  since  a  blood-vessel  contracted  by 


150  MINOE    GYNECOLOGICAL    MAISTIPULATIONS. 

cold  expands  to  a  greater  caliljre  unless  the  inevitable  reaction  is  post- 
poned as  long  as  j)racticable  ;  if  used  for  congestion  or  hemorrhage,  there- 
fore, cold  must  be  applied  continuously  until  permanent  contraction  is  ob- 
tained or  a  clot  forms  in  the  bleeding  vessel.  The  contractile  effect  of  hot 
water  was  at  first  thought  to  be  more  permanent,  and  the  unpleasant 
shock  and  reaction  of  cold  applications  are  avoided.  Hot  water  was, 
therefore,  to  be  preferred  as  an  astringent  and  styptic  to  cold  water. 
More  recent  observations  have  shown,  however  (as  is  also  my  experience), 
that  while  hot  water  is  an  efl&cient  hemostatic  for  the  moment,  its  effect  is 
but  evanescent,  and  that  the  hemorrhage  is  very  liable  to  recur  in  a  short 
time ;  as  a  hemostatic,  therefore,  cold  is  more  rehable ;  as  a  remedial 
agent  in  local  congestion,  where  it  must  be  frequently  repeated,  heat,  how- 
ever, is  preferable.  If  the  influence  of  medicinal  astringents  be  desii'ed  in 
addition  to  that  of  heat,  the  last  pint  or  two  of  a  hot  injection  may  be 
medicated  ;  and  this  is  the  best  method  of  administering  these  remedies. 

The  medicinal  astringents  used  for  vaginal  injections  are  of  both  min- 
eral and  vegetable  origin.  The  minerals  are  :  alum,  the  sulj)hates  of  zinc 
and  coj)per  ;  the  nitrates  of  silver  and  aluminium,  the  persulphate  of  iron  ; 
the  tincture  of  the  chloride  of  iron  ;  the  permanganate  and  chlorate  of 
potash ;  the  acetate  of  lead,  the  chloride  of  zinc.  The  vegetable  astringents 
are  chiefly  such  as  contain  tannic  acid  :  pure  tannic  acid,  decoctions  of 
oak  bark,  cinchona  bark,  nutgalls,  willow  bark  ;  claret  wine,  "\T.negar,  pyro- 
ligneous  acid.  The  strength  of  the  solutions  of  the  zinc,  alum,  silver,  cojd- 
per,  lead,  and  iron  salts,  is  generally  one  to  two  per  cent.  The  perman- 
ganate of  potash  will  require  to  be  used  at  the  strength  of  1  to  400,  at 
least,  if  any  effect  is  to  be  produced  as  an  astringent.  The  objection  to 
it  is  the  stains  produced  by  it  on  the  Hnen,  an  objection  quite  as  vaHd  as 
regards  the  solution  of  silver-nitrate,  u'on,  and  tannin,  all  of  which  make 
almost  indelible  spots.  The  tannin  is  used  in  proportions  of  4 — 5  to  100 
parts.  If  applied  early,  oxalic  acid  will  remove  the  stains  of  tannin.  Of 
the  various  decoctions  of  barks  containing  tannin  mentioned,  the  propor- 
tion used  is  generally  one  ounce  of  powdered  bark  to  one  quart  of  water, 
keeping  the  amount  of  water  always  the  same  until  the  active  jDrinciiDles 
of  the  bark  are  thoroughly  extracted  ;  after  being  strained,  the  decoction 
is  ready  for  use,  and  may  be  bottled  and  put  away  indefinitely.  A  vege- 
table astringent  which  I  have  used  vrith  good  results  in  vaginal  leucor- 
rhea,  chiefly  of  the  subacute  type  (vaginitis),  is  the  fluid  extract  of  hy- 
drastis  Canadensis,  |-  to  1  ounce  to  the  pint.  Astringent  injections  should 
be  used  cool,  j)erhaps  even  cold,  if  the  patient  bears  such  a  temperature 
well.  It  is  an  excellent  rule  to  wash  out  the  vagina  with  tepid  water,  or 
with  a  weak  disinfectant  before  introducing  the  astringent  solution ;  or 
the  mucus  may  be  removed  by  a  mild  injection  of  caustic  potash  or  soda 
(1 — 2  to  1,000).  If  the  solutions  are  mild,  and  the  salts  contained  in  them 
do  not  exert  a  corrosive  action  on  metal  or  rubber,  they  may  be  injected  with 
the  ordinary  metal  and  rubber  syringes  and  irrigators.  If  they  are  corrosive 
(as  the  nitrate  of  silver,  iron,  permanganate  of  potash),  a  large  straight 
glass  sp'inge  should  be  used.     The  nitrate  of  silver  is  but  rarely  employed 


VAGINAL    INJECTION    APPARATUSES,    AND    THEIR    USE.       151 

as  an  injection,  because  the  quantity  necessary  for  an  injection  would  ren- 
der its  habitual  use  rather  expensive,  and  because  it  has  been  found  that 
more  good  is  done  by  the  aiDpUcation  through  a  speculum  of  a  stronger 
solution  than  would  be  advisable  as  an  injection  by  the  patient  herself. 

A  combination  of  astringents  often  acts  much  better  than  one  alone, 
and  the  article  should  occasionally  be  changed.  The  addition  of  carbolic 
acid  (1  to  100)  to  mineral  astringent  injections  often  proves  beneficial, 
particularly  if  there  is  a  subacute  vaginitis  present.  A  combination  fre- 
quently used  by  me  in  cases  of  vulvo-vaginitis  with  profuse  yellowish 
discharge  and  highly  congested  vaginal  mucosa,  is  alum  and  the  sulphate 
of  zinc,  the  borate  of  soda  and  pure  cai'bolic  acid,  of  each  one  ounce, 
dissolved  in  one  quart  of  water ;  of  this  two  to  four  tablespoonfuls  are 
added  to  a  pint  of  tepid  water,  and  a  pint  of  this  solution  is  injected  every 
three  to  foiu'  hours,  always  preceded  by  a  tepid  water  or  soapsuds  injection. 
As  a  rule,  astringent  injections  should  be  so  administered  as  to  keep  the  so- 
lution in  the  vagina  for  at  least  a  few  minutes  ;  the  recumbent  position  with 
elevated  hips  is  therefore  the  position  for  the  purpose.  I  am  aware,  how- 
ever, that  very  few  vaginal  injections  are  administered  in  this  manner, 
the  large  majority  of  women  using  the  crouching  or  sitting  posture,  and 
deriving  proportionately  less  benefit.  It  is  important  always  to  caution 
patients  against  the  staining  of  their  linen  by  an  injection  fluid,  and  to 
recommend  them  to  wear  napkins  after  the  injection  when  such  a  fluid 
has  been  prescribed.  As  a  rule,  agents  which  do  not  permanently  stain 
the  Hnen  should  be  chosen  for  ordinary  injections ;  if  other  articles,  such 
as  tannin,  nitrate  of  silver,  iron,  or  sti'ong  solutions  of  permanganate  of 
potash,  are  employed,  it  will  be  found  more  effectual  to  apply  them  through 
a  speculum  two  or  three  times  a  week,  at  a  strength  proj)ortionate  to  the 
effect  desired,  and  to  direct  the  milder,  non-staining  injections  in  the  intei'- 
val.  This  is  the  manner  in  which  I  treat  the  majority  of  cases  of  chronic 
leucorrhea  or  vaginitis,  whenever,  be  it  understood,  that  symj)tom  is  suf- 
ficiently intense  to  require  local  treatment. 

The  best  alterative,  stimulant  injection  for  the  promotion  of  absorption 
of  the  products  of  pelvic  peritonitis  and  cellulitis,  and  of  the  redundant 
tissue  in  subinvolution  and  hyperplasia  of  the  utenis  is  always  hot  water, 
in  large  quantities,  propelled  with  a  cei'tain  amount  of  force.  But  where 
this  force  is  not  obtainable,  and  even  where  it  is,  the  addition  of  some  sub- 
stance containing  iodine  has  been  found  to  be  of  value.  We  thus  add  to 
the  hot  water  a  certain  proportion  of  simple  or  compound  tincture  of 
iodine  ( 3  j.  to  the  pint),  or  iodide  of  potash  in  the  same  or  stronger  pro- 
portion ;  or  sea-  or  rock-salt  (|- — 1 — 2  ounces  to  the  pint,  or  a  handful  to 
the  basin  of  water)  ;  or  the  imported  brine  from  the  baths  of  Ki-euznach, 
Kissingen,  or  Reichenhall  should  be  added  to  the  douche.  As  it  is  the 
iodine  and  bromine  contained  in  these  salts  and  fluids  to  which  the  altera- 
tive effect  is  due,  the  coarser  the  preparation  the  better ;  I  therefore  always 
recommend  the  common,  unelarified  salt  in  preference  to  the  nicely-pre- 
pared sea-  or  table-salt.  The  salt  solutions  are,  in  my  opinion,  more  bene- 
ficial than  the  weak  iodine  injections.     In  all  cases  it  is  essential  that  the 


152  MINOR    GYNECOLOGICAL    MANIPULATIONS. 

water  be  as  hot  as  can  be  borne.  The  addition  of  iodide  of  potash  to  the 
injection-fluid  will  probably  be  feasible  only  in  the  better  class  of  practice, 
since  the  expense  of  the  drug  will  render  its  employment  in  the  quantity 
necessary  to  prove  beneficial  as  injection  inexpedient  for  poor  patients.  In 
my  opinion,  common  rock-salt  answers  quite  as  well.  Patients  living  at 
the  seashore  can  use  ordinary  sea-water  heated  to  the  desh*ed  degree  as  a 
vaginal  injection. 

The  emollient  injections  consist  of  decoctions  of  flaxseed,  sHppery-elm 
bark,  marshmallow  root,  poppyheads,  gum  arable,  milk,  glycerine,  melted 
vaseline,  sweet  or  castor  oil,  etc.  They  are  used  in  acute  inflammatory 
conditions  and  wounds  of  the  vagina,  as  they  may  occur  after  difficult 
forceps  labors,  burns  from  caustics,  and  after  the  operation  for  stenosis  or 
atresia  vaginse.  Thek  object  is  expressed  in  their  name.  The  decoctions 
should,  of  course,  be  strained  ;  the  glycerine  maybe  used  pure,  or  mixed 
with  water  in  different  proportions.  All  the  decoctions  and  the  glycerine 
may  be  injected  through  the  ordinary  rubber  syringe;  the  oils  are  best 
applied  through  a  glass  sp'inge,  as  the  rubber  is  difficult  to  clean.  All 
emollient  injections  should  be  used  tepid,  unless  the  patient  prefers  them 
cool. 

Irrigation  of  the  vagina  with  tepid  water,  if  long  continued,  acts  as  an 
emolhent,  and  local  as  well  as  general  anesthetic,  precisely  as  a  warm  bath 
soothes  general  irritability. 

Narcotic  injections  contain  various  quantities  of  the  narcotic  drugs, 
chiefly  opium,  hyoscyamus,  and  conium,  also  stramonium.  Thus  one 
drachm  or  more  of  the  tincture  of  one  of  these  agents  may  be  added  to  the 
pint  of  warm  water,  and  the  injection  repeated  as  often  as  occasion  de- 
mands. Or  the  infusion  or  decoction  of  poppyheads  may  be  used.  Or 
one  of  the  bromides  (of  potash,  sodium,  ammonium)  may  be  dissolved  in 
water  in  the  proportion  of  3  j.  to  3  ss.  to  the  pint,  and  injected.  Or 
the  hydrate  of  chloral  may  be  used  in  somewhat  smaller  quantity 
(  3  j.  to  ij.  to  the  pint)  ;  this  agent  also  acts  as  a  disinfectant,  and  is,  there- 
fore, particularly  indicated  in  the  cases  of  cancer,  where  disinfection  and 
local  anesthesia  are  both  desired. 

The  bromides  I  have  found  of  real  benefit,  in  cases  of  so-called  "  irri- 
table uterus,"  diffuse  pelvic  pains,  and  hystero-neuroses  in  various  parts 
of  the  body.  Injections  containing  them  are  best  administered  at  bed- 
time. I  have  repeatedly  seen  a  refreshing  night's  sleep  follow  the  vaginal 
injection  of  one  drachm  of  bromide  of  potash  to  a  pint  of  water. 

The  opiates  and  other  narcotics  first  named  may  also  be  used  in  similar 
conditions,  but  are  more  applicable  to  cases  of  uterine  cancer.  All  these 
injections  should  be  taken  in  the  regulation  position,  with  elevated  hips, 
and  the  patient  should  remain  in  that  position  for  fifteen  to  thirty  minutes 
afterward. 

The  indications  and  utility  of  vaginal  injections  have  to  some  extent  been 
incidentally  referred  to  in  the  previous  sections. 

I  may  mention  here  one  species  of  injection  which  I  have  not  before 
referred  to,  viz.,  that  of  alkahne  solutions  for  excessive  acidity  of  the  va- 


VAGINAL    INJECTION    APPARATUSES,    AND    THEIR    USE.       153 

ginal  discliarge,  whereby  the  spermatozoa  are  killed  and  sterility  ensues. 
This  acidity  predominates  in  blondes,  especially  with  red  hair  (Pajot), 
and  is  easily  detected  by  the  peculiar  odor  on  withdrawing  the  fino-er  or 
passing  the  speculum.  Injections  of  carbonate  and  borate  of  soda  and 
carbonate  of  potash,  |  ss.  to  the  pint,  or  stronger,  have  been  recom- 
mended since  Sims'  investigations  on  the  causes  of  sterility,  to  be  used 
before  retiring  to  rest  each  night.  Byasson  advises  a  liquid  for  the  pui'- 
pose,  composed  of  two  ounces  of  phosphate  of  soda,  one  white  of  eo-"-,  to 
one  quart  tepid  water,  in  which  spermatozoa  have  been  kept  alive  for 
twelve  days  at  a  temperature  of  36°  C. 

It  is  perhaps  not  out  of  place  to  say  a  few  words  here  about  the  indica- 
tions for  the  use  of  ordinary  tepid,  cleansing,  vaginal  injections.  As  a 
rule,  the  physician  is  not  consulted  either  as  to  necessity,  time,  frequency, 
or  coimterindications  of  these  injections.  But  he  should  consider  that  he 
may  do  good  and  avert  damage  by  counselling  his  patients  in  this  matter. 
It  is  surprising  how  little  even  educated  women  think  of  attending  to  the 
regular  cleansing  and  bathing  of  their  sexual  organs.  The}^  may  take  full 
baths  occasionally,  but  in  the  interval  it  does  not  occur  to  them  that  their 
vulvar  and  anal  regions  need  quite  as  much  (if  not  more)  washing  than  their 
hands  and  faces.  Every  woman,  indeed,  should  wash  her  genitals  with  a 
soft  cloth  or  sponge  after  each  urination,  and  certainly  ever}^  morniug  and 
evening.  A  vaginal  injection  is,  of  course,  not  necessary  so  often.  Women 
who  do  not  suffer  from  habitual  leucorrhea  need  not  cleanse  their  vaginal 
canals  of  tener  than  once  a  week  or  so  ;  if  they  have  a  habitual  discharge, 
one  or  two  injections  a  day  should  be  used,  generally  of  some  mild  astrin- 
gent, alkaline  solution,  or  of  soajDSuds.  A  very  common  time  for  a  vaginal 
injection  with  those  of  our  ladies  (unfortunately,  by  far  too  large  a  number) 
who  desh'e  to  prevent  increase  of  family,  is  immediately  after  sexual  inter- 
course. It  should  be  understood  by  the  physician  and  impressed  upon  the 
lady,  that  such  injections,  aside  from  the  doubtful  morality  of  the  proceed- 
ing, are  objectionable  and  injui'ious,  no  matter  whether  the  water  used 
be  cold  or  warm,  or  medicated.  While  a  cold  injection  is  positively  in- 
jurious by  the  sudden  shock  the  cold  gives  to  the  (at  that  time)  highly 
vascular  and  congested  pelvic  organs,  and  by  the  inevitable,  chronic  con- 
gestion of  these  organs  which  must,  in  time,  follow  this  interference  with 
nature,  even  warm  injections  act  harmfully  by  removing  the  emollient 
seminal  fluid  in  which  the  turgid  organs  are  bathed  after  coition.  Look 
upon  the  evils  of  a  too  rapid  succession  of  jDregnancies  and  the  prevention 
of  this  evil  by  the  checks  so  enthusiastically  advocated  by  the  discijiles 
of  the  Malthusian  school  in  whatever  light  we  may,  we  cannot  close  our 
eyes  to  the  indisj)utable  fact  that  all  such  interference  with  the  physio- 
logical performance  of  the  function  of  repi-oduction — with  the  designs  of 
nature,  as  some  express  it — is  wrong,  and  will  sooner  or  later  bring  its  own 
retribution. 

During  the  menstrual  flow,  of  course,  vaginal  injections  are  prohibited, 
not  that  a  gentle,  tepid  injection  would  do  harm,  but  because  the  jiopular 
voice  and  opinion  is  against  them  and  they  are  not  necessary.     But,  after 


154  MIiS"CR    GYNECOLOGICAL    MANIPULATIONS. 

the  cessation  of  the  flow,  a  tepid,  cleansing  injection  would  be  both  proper 
and  serviceable  in  removing  the  debris  of  the  uterine  flow. 

It  is  scarcely  necessary  to  point  out  more  specifically  in  what  class  of 
cases  the  vagina  needs  to  be  washed  out  antiseptically,  as  the  character 
and  amount  of  the  discharge  will  be  sufficient  indications  for  the  necessity, 
frequency,  and  strength  of  the  injection. 

The  indications  for  astringent  injections  may  also  be  briefly  summed 
up  under  two  headings  :  a  vaginal  discharge  of  mucous  or  muco-purulent 
character,  and  hemorrhage  from  uterus  or  vagina.  In  acute  or  subacute 
inflammatory  conditions  of  the  vagina  or  cervix,  with  or  without  abrasion 
of  epithelium,  the  nitrate  of  silver  solution  is  the  best  application.  As 
already  stated,  it  is  advisable  to  apply  it  repeatedly  through  a  speculum, 
and  direct  a  mild  astringent  injection  three  or  four  times  daily  in  the  in- 
terval. For  ordinary  leucorrhea  the  astringents  already  enumerated  may 
be  either  used  alone,  or  in  the  interval  between  stronger  apphcations  made 
through  the  speculum. 

In  hemorrhage,  which  is  usually  from  the  endometrium  or  the  cervix, 
rarely  from  the  vagina  proper,  the  thermic  astringents,  very  hot  or  very 
cold  water,  will  act  better  than  mild  medicinal  astringents.  Concentrated 
solutions  cannot  be  applied  as  injections  for  reasons  already  stated,  but 
must  be  introduced  through  a  speculum,  and  will  doubtless  be  required 
in  all  cases  of  obstinate  or  profuse  hemorrhage.  If  the  hemorrhage 
comes  from  the  endometrium,  it  will  be  arrested  only  by  the  influence  on 
the  whole  pelvic  circulation  of  high  or  low  temperature,  and  I  have  al- 
ready stated  my  preference  for  hot  water.  Still,  I  have  occasionally  seen 
uterine  hemorrhage  checked  by  the  injection  of  vinegar  and  ice-water, 
equal  parts,  and,  as  a  rule,  I  think  the  hemostatic  effect  of  cold  applications 
more  permanent  than  that  of  heat.  If  the  flow  be  a  menorrhagia — profuse 
menstruation — especially,  but  even  in  any  uterine  hemorrhage  other  than 
mere  stillicidium  from  vascular  relaxation,  a  cold  styptic  injection  is  haz- 
ardous, since  it  might  not  only  arrest  the  flow,  but  also  produce  the  unde- 
sii'ed  result  of  lighting  up  a  pelvic  cellulitis  or  peritonitis.  This,  hot  water 
would  not  do.  If  the  hemorrhage  proceeds  from  an  accessible  surface,  it 
is  always  best  to  endeavor  to  arrest  it  by  direct  applications  through  a 
speculum,  which  may  be  followed  and  confirmed  by  hot  injections,  medi- 
cated or  not,  rather  than  attempt  the,  as  regards  permanent  effect,  rather 
uncertain  injections,  hot  or  cold.  Although  a  direct  styptic  or  astringent 
effect  is  not  expected  on  the  endotrachelian  surface,  the  fluid  of  a  vaginal 
injection  will  enter  the  cervix  if  the  external  os  is  patulous  or  positively 
gapes,  as  is  the  case  after  ununited  laceration  and  chronic  endotrachelitis. 
Thus  ajDpKed,  injections  may  act  beneficially  on  pathological  conditions  of 
the  cervix. 

Astringent  injections  in  chronic  vaginal  discharges  generally  require 
to  be  continued  for  a  long  period,  and  the  astringent  should  occasionally 
be  changed,  if  the  one  in  use  proves  ineffectual  after  a  fair  trial  of  several 
weeks  ;  or  the  strength  should  be  increased. 

The  indications  for  alterative,  emollient,  and  narcotic  injections  have 


VAGINAL    INJECTION    APPARATUSES,    AND    THEIE    USE.      155 

already  been  referred  to.  The  most  valuable  results  are  obtained  from 
the  alterative  injections  in  cases  of  areolar  hyperplasia  or  subinvolution 
of  the  uterus,  and  acute,  subacute,  and  chronic  inflammation  of  the  pelvic 
peritoneum  and  cellular  tissue.  The  treatment  of  these  affections  with- 
out the  assistance  of  that  greatest  of  all  alteratives,  heat,  would  be  dis- 
couraging indeed.  And  this  brings  me  to  the  discussion  of  the  rationale 
of  hot  injections  as  a  therapeutic  agent  in  producing  contraction  of  blood- 
vessels and  absorption  of  hyperplastic  tissue  and  plastic  exudation. 

The  immediate  effect  of  cold  when  applied  to  a  living  tissiie  is  to  pro- 
duce shrinking  of  the  tissues  and  reflex  contraction  of  the  blood-vessels ; 
when  the  cold  is  removed,  this  effect  rapidly  wears  off  and  the,  in  every 
animate  body,  inevitable  reaction  follows,  the  blood-vessels  dilate  to  a  still 
greater  calibre  than  before,  and  the  congestion  is  increased  instead  of 
diminished.  With  heat  the  order  of  effect  is  reversed  :  First,  the  capilla- 
ries are  relaxed,  the  tissues  swell,  but  soon  the  stimulus  of  the  heat  ex- 
cites reflex  action,  the  vessels  contract  and  the  tissues  shrink,  and  this 
effect  continues  much  longer  after  the  removal  of  the  heat  than  it  does 
after  the  application  of  cold.  Besides,  the  nutrition  of  the  part  is  not 
interfered  with  by  heat,  as  it  is  by  cold  ;  for  the  relaxed  capillaries  regain 
their  tone,  and  transmit  the  blood  more  rapidly,  while  the  contraction 
of  cold  is  so  severe  as  to  arrest  circulation  entirely,  if  continued.  Thus 
in  their  immediate  effects  extreme  heat  and  extreme  cold  are  identical  ; 
it  is  in  the  permanence  of  the  effect,  and  in  its  influence  on  the  faculty  of 
absorption  that  they  differ.  The  contractile  effects  of  continued  heat  are 
vividly  exemplified  by  the  bleached  and  shrivelled  hands  of  washerwomen, 
and  the  blanched  appearance  of  the  skin  under  a  poultice  (Emmet). 

According  to  Emmet  all  pelvic  congestion  is  venous,  and  the  term 
"  chronic  inflammation,"  so  far  as  it  applies  to  the  organs  in  that  cavity, 
is  a  misnomer,  simply  because  the  arterial  vessels  are  not  involved  in  that 
process.  Although  hot  water  will  contract  the  arterioles  also  and  thus 
perhaps  abort  an  attack  of  acute  inflammation,  it  is  mainly  in  the  chronic 
venous  congestion  constituting  the  chief  factor  in  subinvolution,  hyjDer- 
plasia,  and  old  pelvic  hyperemia,  that  its  use  is  so  eminently  beneficial. 
Its  effect  is  naturally  greatly  enhanced  by  raising  the  hips  and  aiding  the 
emptying  of  the  veins  by  gTavitation.  This  point  is  particularly  insisted 
upon  by  Emmet.  The  unloading  of  the  venous  plexuses  by  gravitation 
is  assisted  and  confirmed  by  the  hot  water,  and  the  contraction  of  the 
vessels  maintained  by  keeping  the  patient  in  the  recumbent  position  for 
some  time  afterward.  The  most  benefit  is,  therefore,  derived  fi-om  the  hot 
injections  when  given  at  bedtime,  the  patient  not  rising  from  her  couch 
until  the  next  morning.  It  is  obvious  that  success  in  this  treatment — that 
is,  permanent  restoration  of  tone  and  calibre  of  the  blood-vessels — dejDends 
mainly  on  the  high  degree  of  temperature,  large  quantity,  long  duration, 
and  steady  perseverance  with  which  these  injections  are  administered,  not 
omitting  the  proper  position  with  elevated  pelvis. 

Little  by  little,  as  the  patient  improves,  the  temperature  of  the  injec- 
tions may  be  gradually,  almost  imperceptibly  lowered,  the  amount  and  force 


156  MINOR    GYNECOLOGICAL    MANIPULATIONS. 

reduced,  and  but  one  injection  a  day  given,  until  the  temperature  of  60°  F. 
is  reached  and  they  are  discontinued.  Emmet  advises  their  continuance 
during  some  months  for  several  days  after  each  menstrual  period,  at  a  tem- 
perature shghtly  above  blood  heat,  in  order  to  avert  any  relapse  at  this 
critical  period,  and  also  at  a  higher  temperature,  if  from  any  cause  a  pel- 
vic congestion  or  inflammation  seems  imminent  at  any  time. 

The  value  of  these  systematic,  carefully  administered,  and  persever- 
ingly  continued  copious  hot  vaginal  injections  is  certainly  not  overesti- 
mated by  their  author  and  chief  advocate,  Emmet.  Hot  injections  in 
uterine  disease,  it  js  true,  were  recommended  years  ago  by  SediUot, 
Trousseau,  Kiwisch,  and  Scanzoni,  but  never  with  the  degree  of  system 
and  perseverance  necessary  to  a  successful  result.  It  is  certain  that  they 
fell  into  disuse,  except  in  the  one  instance  of  the  artificial  induction  of 
premature  labor  by  the  forcible  hot  vaginal  douche  according  to  Kiwisch ; 
and  when  I  was  studying  gynecology  under  Scanzoni,  eighteen  years  ago, 
no  mention  was  ever  made  of  this  treatment  for  female  pelvic  affections. 
It  is  true,  that  warm  baths  and  injections  of  brine  were  recommended,  but 
the  chief  benefit  of  these  baths  was  attributed  to  the  mineral  constitu- 
ents, not  to  the  hot  water.  Since  then  the  revulsion  of  feeling  has  been  so 
great  that  cold  water  injections  have  fallen  almost  entirely  into  disuse,  and 
hot  water  has  been  substituted  for  it  in  all  classes  of  uterine  disease  by 
all  gynecologists  who  follow  the  lead  of  the  modern  pelvic  pathology  so 
ably  and  logically  demonstrated  by  Emmet.  The  importance  of  carefully 
attending  to  all  the  details  of  this  treatment,  as  described  at  length  in  the 
preceding  pages,  should  be  impressed  on  both  physician  and  patient  as 
essential  to  success. 

To  give  special  indications  for  hot  vaginal  injections  scarcely  seems 
necessary  after  all  that  has  been  said  here  on  the  subject.  Suffice  it  to 
say  that  they  are  indicated  in  all  conditions  of  chronic  venous  congestion 
of  the  pelvic  organs,  in  subinvplution  and  hyperplasia  of  the  uterus,  par- 
ticularly ;  further,  in  chronic  ovarian  congestion,  so-called  "  chronic  ovari- 
tis," and  in  all  cases  where  the  pelvic  cellular  tissue  presents  evidence  of 
the  previous  occurrence  of  inflammatory  exudation  and  subsequent  in- 
duration, so-called  "  chronic  pelvic  cellulitis  and  peritonitis."  Further, 
acute  attacks  of  this  latter  affection,  or  of  metritis  or  ovaritis,  may  be 
aborted  by  hot  injections,  if  used  at  the  very  outset.  Acute,  subacute, 
and  chronic  vaginitis,  leucorrhea  from  want  of  tone  of  the  vaginal  tissues, 
are  also  indications. 

Nervousness  and  sleeplessness  in  a  hysterical  woman  may  be  allayed 
by  prolonged  hot  vaginal  injections  at  bedtime,  in  very  much  the  same 
manner  as  a  long  warm  sitz-bath  will  quiet  and  induce  sleep. 

An  indication  which  is  not  ordinarily  considered  in  directing  the  pro- 
longed use  of  hot  vaginal  injections,  is  that  of  hemostasis.  But  the  ra- 
tionale is  the  same  as  when  they  are  used  in  venous  congestion,  viz.,  the 
contraction  of  the  blood-vessels.  Hot  injections  ai'e  therefore  indicated  in 
cases  of  uterine  or  vaginal  hemorrhage,  chiefly  when  the  bleeding  surface 
can  be  directly  touched  by  the  water,  as  in  erosions,  granulations,  lacera- 


VAGINAL    INJECTION"    APPARATUSES,    AND    THEIR    USE.        157 

tion,  epithelioma,  or  real  carcinoma  of  the  cervix.  But  even  when  the  flow 
comes  from  the  uterine  cavity,  as  in  menorrhagia  from  whatever  cause 
(functional,  vegetations,  fibroids,  sarcoma),  the  contraction  of  all  pelvic 
blood-vessels  by  the  heat  will  diminish  the  flow  from  the  uterus,  although 
the  bleeding  surface  is  not  directly  touched.  It  is  thus  not  only  allowable, 
but  advisable  (unless  special  counterindications  exist)  to  control  or  check 
a  profuse  menstrual  flow  by  hot  injections.  No  harm  can  result  from  tliis 
practice,  wherein  it  differs  decidedly  from  the  not  uncommon  but  hazardous 
use  of  cold  injections  for  the  same  purpose.  Before  operating  on  the 
external  genitals,  vagina,  or  uterus,  a  very  beneficial  effect  can  be  j)i"o- 
duced  by  rendering  the  parts  anemic  by  hot-water  applications  or  in- 
jections immediately  preceding  the  operation.  The  saving  of  blood  to  the 
patient,  and  the  convenience  of  but  slight  oozing  to  the  operator,  are 
points  well  worth  considering. 

An  innovation  in  plastic  operations  on  the  female  genital  organs,  chiefly 
colpo-perineorraphy,  has  recently  been  introduced  in  Germany,  in  the  use 
of  the  irrigation  with  hot  or  cold  sublimated  or  carbolized  water  of  the 
field  of  operation,  in  place  of  the  sponging  heretofore  and  elsewhere  still 
in  vogue.  As  the  patient  in  these  operations  occupies  the  dorsal  position  at 
the  edge  of  the  table,  the  water  flows  directly  into  a  vessel  underneath  the 
table  ;  for  operations  in  the  lateral  decubitus  and  through  Sims'  speculum 
this  method  would  obviously  not  be  so  applicable. 

Counterindications  and  Dangers. — I  know  of  but  one  objection  to  a 
proper  vaginal  injection  for  a  given  case,  and  that  is  the  possibility  of  in- 
jecting the  fluid  directly  into  the  uterine  cavity.  The  manner  in  which 
this  occurs,  through  a  lacerated  or  gaping  cervix  and  patulous  internal  os, 
particularly  in  a  retroverted  and  prolapsed  uterus,  and  the  dangers  of  this 
accident  have  already  been  fully  discussed.  Also  the  means  of  averting  it. 
Other  than  this,  I  can  conceive  of  no  condition  in  which  a  properly  indi- 
cated injection  (hot,  cold,  or  medicated,  as  the  case  demands)  could  be 
injurious  when  carefully  applied  according  to  the  rules  above  given.  I 
need  scarcely  say  that  pregnancy  would,  of  course,  counterindicate  a  hot 
injection.  Emmet  speaks  of  occasionally  meeting  cases  in  which  so  much 
discomfort  and  pelvic  weight  was  experienced  after  the  hot  injections,  as 
to  lead  him  to  discontinue  them.  He  confesses  his  inability  to  explain  the 
why  and  wherefore  of  this  occurrence,  but  says  that  he  long  since  found 
that  the  injection  in  these  cases  is  well  boi'ne,  if  the  temperature  does  not 
exceed  95°  at  first,  and  is  very  slowly  increased.  I  have  noticed  similar 
effects,  besides  hearing  complaints  of  faintness,  weakness,  and  nervousneys 
as  immediate  consequences  of  the  hot  injection.  I  have  invariably  over- 
come these  symptoms  in  the  manner  prescribed  by  Emmet. 

The  possibility  of  lighting  up  a  fresh  or  rekindling  an  old  pelvic  in- 
flammation by  the  forcible  injection  of  hot  water  into  the  vagina,  W'hich 
has  been  advanced  by  some  of  the  old-school  gynecologists,  is  not  to  be 
admitted  for  a  moment.  The  first  instance  of  such  an  occurrence  is  still 
to  be  reported. 


158  MINOE    GYNECOLOGICAL    MANIPULATIOI^S. 


6.  Through  Specula. 

The  indications  for  the  application  of  medicinal  agents  to  the  vagina  or 
cervix  through  the  medium  of  a  speculum  are  such  conditions  of  these 
parts  as  call  for  direct  treatment  with  substances  too  concentrated  to  be 
used  by  iajection.  Such  conditions  are  :  Cervix  :  Erosion  with  or  with- 
out papillary  hypertrophy,  laceration  with  eversion  and  cystic  hypei-plasia, 
endotrachelitis  with  patulous  os  ;  ordinary  areolar  hypei-plasia,  malignant 
disease,  specific  ulceration.  Vagina:  Acute  vaginitis,  granular  vaginitis, 
obstinate  chronic  leucorrhea,  venereal  warts.  Experience  has  shown  that 
the  allowable  strength  of  vaginal  injection  fluids  is  entirely  inadequate  to 
exert  the  necessary  irritant  astringent  or  styptic  effect  on  these  condi- 
tions, and  that  powerful  caustics,  astringents,  or  styptics  must  be  directly 
applied  to  the  diseased  surface.  This  is  possible  only  through  one  of  the 
various  forms  of  specula,  by  which  the  healthy  tissues  are  protected  from 
the  agent.  In  this  manner  either  the  cervix  alone,  or  cervix  and  vagina, 
or  any  one  portion  of  the  vagina  may  be  touched  by  the  agent,  without 
the  normal  internal  or  external  parts  being  affected. 

Besides  the  conditions  of  the  cervix  and  vagina  named  as  calhng  for 
strong  direct  applications,  there  are  subacute  and  inflammatory  processes 
in  the  pelvic  cellular  tissue  and  peritoneum  and  the  ovaries,  which  are 
much  benefited  by  the  apphcation  of  strong  counter-irritant  or  absorbent 
agents  to  the  vaginal  roof.  I  have  met  with  excellent  results  from  such 
measures  in  chronic  pelvic  celluhtis  and  peritonitis  and  chronic  ovaritis,  if 
continued  persistently  for  a  long  period  in  conjunction  with  the  systematic 
use  of  hot  injections. 

Occasionally  a  hyperplastic  condition  of  the  vagina  is  met  with  as  the 
result  of  chronic  vaginitis,  a  so-called  pachy-vaginitis  chronica,  which  is  re- 
heved  by  similar  strong  absorbent  applications. 

In  areolar  hyperplasia  and  subinvolution  of  the  whole  uterus,  I  have 
found  applications  to  the  whole  intravaginal  portion  of  the  cervix  of  strong 
tincture  of  iodine  to  aid  the  hot  injections  in  reducing  the  enlargement  and 
to  relieve  very  decidedly  the  peculiar  local  neuralgic  and  general  hysteri- 
cal symptoms  so  commonly  met  with  in  those  affections.  Such  relief,  to 
be  sure,  is  generally  but  temporary  ;  still,  in  such  intractable  affections  as 
old  hyperplasia  uteri  even  that  much  is  worth  having. 

The  most  common  conditions  in  which  the  application  of  concentrated 
agents  in  substance  or  solution  to  the  vagina  or  cervix  is  indicated  are  : 
hypersecretion  of  the  vaginal  mucous  membrane,  either  acute  or  chronic ; 
erosion  of  the  cervix  and  external  os,  and  mahgnant  disease  of  the  cervix. 

An  apphcation,  which  is  frequently  required,  as  a  styptic  and  caustic, 
in  malignant  disease  of  the  cervix,  is  the  actual  cautery,  either  by  means 
of  the  old-fashioned  cautery  iron,  PaqueUn's  thermo-cautery,  or  the  plati- 
num tip  of  the  galvano-cautery  battery. 


APPLICATIOIS'S    THROUGH    THE    SPECULUM.  159 


Substances  Applied  through   the   Speculum,   and  Manner  of  Appdying 

them. 

Any  of  the  medicinal  agents  enumerated  in  the  preceding  chapter  as 
serviceable  in  a  highly  diluted  condition  as  vaginal  injections  may  be  ap- 
plied to  the  cervix  or  vaginal  walls  in  a  pure  or  more  or  less  concentrated 
state  through  a  speculum.  But  by  no  means  aU  of  these  agents  are  so 
applied,  since  some  of  them  can  be  replaced  by  remedies  of  gi'eater  effi- 
ciency^ in  their  concentrated  form,  and  the  u.se  of  others  has  by  custom 
been  confined  to  injections.  Thus,  we  are  not  in  the  habit  of  applying  the 
acetate  of  lead,  the  sulphate  of  zinc,  the  permanganate  or  the  chlorate  of 
potassium,  salicyhc  acid,  sulphite  of  sodium,  etc.,  in  substance  or  concen- 
trated solution  through  a  speculum  ;  not  that  they  might  not  be  used  bene- 
ficially, but  that  we  have  other  more  efficient  agents  which  the  speculum 
permits  us  to  use  safely.  On  the  other  hand,  there  are  powerful  remedies, 
like  concentrated  nitric  acid,  bromine,  chromic  acid,  acid  nitrate  of  mer- 
cury, caustic  potash,  which  are  not  used  in  dilute  solution,  but  exert  their 
best  effects  when  applied  in  a  concentrated  form. 

The  effects  to  be  obtained  from  the  various  agents  are  either  astrin- 
gent, caustic,  alterative,  hydragogue,  emollient,  or  narcotic.  Of  astringents, 
those  chiefly  used  in  substance,  or  strong  solution,  or  otherwise,  through 
a  speculum  are  :  tannin,  hydrastis,  alum,  sulphate  of  copper,  tincture  of 
chloride  of  iron,  persulj^hate  of  iron,  acetic  acid  ;  caustics :  nitrate  of  silver, 
carbolic  acid,  nitric  acid,  chromic  acid,  bromine,  acid  nitrate  of  mercury, 
sulphurous  acid,  caustic  potash,  actual  cautery  ;  alteratives  :  iodine,  inform 
of  simple  or  compound  (Churchill's)  tincture,  iodide  of  potash  in  concen- 
trated solution,  iodoform  in  powder  or  solution,  iodide  of  lead,  uuguentum 
hydrargyri  ;  the  only  hydragogue  is  glycerine  ;  emollients :  oHve,  or  poppy 
oil,  vaseHne,  powdered  flaxseed,  or  slippery-elm  bark ;  narcotics :  extract  or 
tincture  of  opium,  or  belladonna,  or  conium,  hydrate  of  chloral,  bromide 
of  potassium,  sodium,  or  ammonium,  iodoform. 

In  accordance  with  the  chemical  properties  of  these  agents  they  are 
applied  through  the  speculum  in  substance  (stick,  crystals,  powder),  or  in 
a  fluid  or  unctuous  form. 

If  applied  in  substance,  they  may  be  either  withdrawn  at  once  on  the 
attainment  of  the  object  (as  after  cauterization  with  stick  of  nitrate  of 
silver,  or  crystals  of  chromic  acid),  or  left  in  apposition  with  the  diseased 
surface  for  a  greater  or  lesser  time,  the  healthy  parts  being  protected  by 
cotton  wads.  If  used  in  fluid  form  (solution,  or  natural  fluid,  as  nitric 
acid,  sulphurous  acid)  they  may  either  be  withdrawn  at  once,  or  remain  in 
contact  with  the  tissues  by  being  conveyed  on,  or  retained  by  cotton  wads, 
introduced  through  the  speculum. 

a.   In  Substance. 

The  agents  which  may  be,  and  frequently  are  applied  in  substance 
(stick,  crystals,  or  powder)  are  :  nitrate  of  silver,  chloride  of  zinc,  caustic 


160  MINOR    GYNECOLOGICAL    MANIPULATIONS. 

potash,  chromic  acid,  tanuin,  iodoform,  persulphate  of  iron,  alum,  sulphate 
of  copper,  iodide  of  lead,  hydrate  of  chloral,  the  bromides. 

The  manner  of  ajjplying  these  substances  is  by  means  of  one  of  the 
three  main  varieties  of  specula  (tubular,  bivalve,  Sims).  As  the  stronger 
ao'ents  are  generally  applied  merely  to  the  cervix,  the  introduction  of  a 
large  tubular  speculum,  if  such  a  one  be  used,  is  advisable  in  order  to  ob- 
tain a  view  of  the  whole  cervix.  The  application  is  then  made  by  more  or 
less  thoroughly  touching  the  diseased  surface  with  'the  stick,  if  nitrate  of 
silver,  sulphate  of  copper,  or  caustic  potash,  be  used  ;  or  thrusting  the 
crystal  or  powder  against  the  cervix  with  a  spatula  or  cotton- wrapped 
stick  (Fig.  87),  if  the  substance  employed  be  in  that  form.  Only  tannin, 
iodoform,  iodide  of  lead,  persulphate  of  iron,  alum,  sulphate  of  copper, 
chloral,  and  the  bromides,  may  be  retained  in  contact  with  the  cervix  for 
twelve  or  twenty-four  hours  ;  the  stronger  salts  should  be  removed  after  a 
few  minutes  by  wiping  them  off  with  a  sponge  on  a  holder,  or  the  cotton- 
wrapped  rubber-stick,  or  by  a  tepid  injection.  The  effects  of  a  caustic 
being  generally  immediate,  there  is  nothing  to  be  gained  by  leaving  an  ex- 
cess of  it  in  contact  with  the  cauterized  part ;  the  excess  should  therefore 
be  removed  or  neutralized,  and  this  is  done  in  the  case  of  the  nitrate  of 
silver  by  an  application  or  injection  through  the  speculum  of  a  solution 
of  chloride  of  sodium. 


Fig   87  —Straight  Whalebone  Stick,  with  Notchecl  End,  for  Wrapping  with  Cotton,  as  Shown  in  Smaller 

Cut. 

For  all  applications  (solid  or  fluid)  to  the  cervix  alone,  the  cylindrical 
speculum  surpasses  the  other  forms,  provided  the  vaginal  orifice  permits 
the  introduction  of  a  sufficiently  large  tube  to  fully  expose  the  cervix. 
The  speculum  should  not  be  too  large,  however,  as  in  that  case  portions 
of  vagina  might  readily  slip  into  its  lumen  beside  the  speculum  and  be 
cauterized  involuntarily.  If  the  agent  is  to  be  kept  in  contact  with  the 
cervix  for  some  time,  care  is  taken  that  the  excess  be  not  too  great,  and  a 
wad  of  cotton  tied  about  its  middle  with  a  stout  string  is  introduced  up  to 
the  cervix  and  firmly  held  there  with  the  dressing-forceps  while  the  tube 
is  withdrawn  ;  the  string  then  projects  from  the  vulva  and  allows  the  re- 
moval of  the  cotton  by  the  patient  herself.  This  cotton  tampon  may  be 
either  dry  or,  what  is  preferable,  wet  and  squeezed  out,  so  that  the  crystal 
or  powder  will  better  cling  to  it  and  remain  where  it  was  placed.  Or,  the 
tip  of  the  conical  tampon  (wet  or  dry)  may  be  sprinkled  with  the  powder 
and  introduced  directly  against  the  cervix. 

In  profuse  hemorrhage  from  the  cervical  cavity,  as  may  occur  in  cer- 
vical cancer  (it  once  happened  to  me  while  curetting  the  cer-\dx,  to  open 
an  eroded  branch  of  the  uterine  artery,  with  the  result  of  almost  fatal 
hemorrhage),  it  may  become  necessary  to  throw  in  the  styptic,  preferably 
the  powdered  persulphate  of  iron,  by  the  spoonful,  until  the  hemorrhage 


APPLICATIOISrS    THROUGH    THE    SPECULUM.  161 

is  arrested.  I  have  thus  packed  the  bleeding  cavitj^  full  of  the  powder, 
each  subsequent  spoonful  coagulating  the  blood  which  oozed  through  the 
preceding  powder  until  a  sufficiently  firm  clot  was  formed  to  arrest  the 
bleeding.  The  application  of  styptic  solutions  on  cotton  to  the  bleeding 
surface  woiild  scarcely  suffice  to  arrest  hemorrhage  of  so  violent  a  char- 
acter as  that  which  I  have  just  described.  When  a  firm  coagulum  has 
once  been  formed,  it  is  well  to  support  it  by  pressure  with  a  column  of 
tampons,  as  wiU  be  described  hereafter.  The  styptic  should  be  kept  as 
much  as  possible  from  the  sound  parts,  particularh^  the  vaginal  surface. 
While  the  more  powerful  agents  are  applied  only  to  the  cervix,  the  milder 
powders  and  crystals,  such  as  tannin,  iodoform,  and  alum,  are  employed 
also  in  inflammatory  or  relaxed  conditions  of  the  vaginal  mucous  mem- 
bi'ane.  Either  of  the  powders  named  may  be  thrown  into  the  speculum 
by  means  of  a  spatula  or  spoon,  and  then,  being  joushed  forward  toward 
the  cervix,  is  brought  in  contact  with  everj^  part  of  the  vagina  by  rotating 
and  withdrawing  the  speculum  until  its  point  almost  reaches  the  orifice, 
when  it  is  again  introduced  merely  half-way  and  a  round  tampon  placed 
in  the  speculum  and  held  in  situ  by  the  forceps  while  the  tube  is  removed. 
In  this  manner  the  powder-covered  walls  of  the  upper  portion  of  the  vagina 
are  allowed  to  approach  each  other,  and  the  powder  is  not  pushed  up  into 
the  fornix,  as  will  be  the  case  if  the  tampon  is  introduced  as  far  as  the 
cervix.  Or,  the  tampon  may  be  moistened,  squeezed  out,  rolled  in  the 
powder,  and  then  pushed  up  to  the  cervix,  when  the  conical  shape  of 
the  tampon  will  place  and  keep  the  powder  in  permanent  contact  with  the 
whole  vaginal  circumference. 

The  substances  named  may  be  applied  pure,  especially  the  tannin. 
But  pure  alum  is  generally  too  strong,  and  gives  decided  pain  ;  it  is  there- 
fore best  diluted  with  equal  parts  of  sugar.  The  strong  unpleasant  odor 
of  the  iodoform  renders  it  decidedly  objectionable  to  patients  going  about 
their  daily  duties  and  mingling  with  other  people.  When  mixed  with 
equal  parts  of  tannin,  or  with  Peruvian  balsam,  the  iodoform  loses  much 
of  its  odor,  and  proves  a  very  efficient  antiseptic,  astringent,  and  alterative. 
One  of  the  best  deodorizers  of  iodoform  is  hydrate  of  chloral,  which  I  have 
recently  been  using  in  this  combination  as  a  local  application  to  the  cervix 
and  vaginal  vault.  In  painful  affections  of  these  parts  (chronic  cellulitis 
and  peritonitis,  carcinoma,  etc.)  the  chloral  forms  a  very  useful  addi- 
tion to  the  iodoform.  The  formula  which  I  employ  is  the  following  : 
Fp .  lodoformi,  hydrat.  chloral,  alcohol,  aa  3  ij.  ;  glycerine,  3  iv.  M. — Sig. 
To  be  applied  on  a  cotton  tampon  and  retained  at  least  twenty-four  hours. 

I  have  described  the  application  of  stick  and  powders  to  cervix  and 
vagina  through  the  tubular  speculum,  which  is  essentially  similar  to  their 
use  through  the  bivalve  ;  with  the  latter,  however,  great  caution  should  be 
observed  to  prevent  the  agent,  if  powerful,  from  touching  healthy  tissue  ; 
and  the  application  of  powders  to  the  vagina  is  not  as  convenient  as 
through  the  tube.  Still,  it  can  readily  be  done  in  the  same  manner  by 
withdrawing  the  bivalve  and  closing  the  lower  half  of  the  vaginal  canal 
with  a  tampon.     These  tampons,  when  used  merely  as  stoppers  to  the 


162  MINOE    GYNECOLOGICAL    MANIPULATIONS. 

escape  of  the  powder,  are  best  introduced  perfectly  dry,  and  should  be 
conical  in  shape  (see  Fig.  92).  Through  the  Sims  speculum  powders  are 
best  applied  on  a  tampon,  the  sui-face  of  which  has  been  covered  with 
some  emollient,  as  vasehne,  or  which  has  been  dipped  in  glycerine  or  oil, 
I  frequently  use  them  in  this  way  in  leucorrhea,  and  chiefly  in  prolapse  of 
the  anterior  or  posterior  vaginal  wall,  or  both,  with  descensus  uteri,  when 
I  wish  to  introduce  a  tampon  of  sufficient  size  to  insure  its  retention.  If 
but  one  wall  of  the  vagina  is  prolapsed  or  relaxed,  the  powder  on  the 
tampon  may  be  hmited  to  that  portion  which  is  placed  against  the  pro- 
lapsed part.  In  widely  gaping  vaginae  the  tampons  may  be  introduced  by 
the  patients  themselves ;  and  in  any  case  they  should  be  retained  by  a 
T-bandage. 

The  powdered  flaxseed  and  shppery-elm  bark  may  be  enclosed  in  small 
muslin  bags  of  the  size  of  an  English  walnut  to  a  hen's  egg,  and  securely 
tied  with  string  ;  they  are  then  dipped  in  boiling  water  and  introduced  up 
to  the  cervix,  either  by  the  physician  through  a  sjDeculum,  or  by  the 
patient's  fingers,  while  the  latter  occupies  a  dorsal  position,  and  are 
retained  for  from  twelve  to  twenty-four  hours.  The  soothing  emollient 
effect  of  these  poultices  is  beneficial  in  various  inflammatory  disorders  of 
the  pelric  organs  (chronic  cellulitis,  ovaritis,  and  metritis).  By  the  addi- 
tion of  one-fourth  to  one-half  teasiDOonful  of  powdered  alum,  borax,  or 
sulphate  of  zinc  to  the  flaxseed  or  elm-bark,  the  poultices  may  be  made 
astringent  as  well  as  emollient  and  absorbent.  Powdered  myrrh  is  also 
reported  to  be  an  excellent  stimulating  adjuvant,  as  also  the  powdered 
root  of  sanguinaria  Canadensis. 

If  a  powerful  caustic,  as  chromic  acid  or  caustic  potash,  is  applied  to 
the  ceiwix  through  the  Sims,  it  is  best  to  protect  the  subjacent  part  of  the 
vagina  by  packing  cotton  between  it  and  the  cervix,  which  is  removed 
when  the  application  is  completed  and  all  excess  of  the  remedy  wiped  off 
or  neutralized. 

If  any  portion  of  the  vagina  is  to  be  touched,  as  in  the  case  of  ulceration 
from  pressure  by  a  too  long  worn  pessaiy,  or  ulceration  of  any  kind,  or 
venereal  papillomata,  the  Sims  speculum  allows  the  best  exposure  of  the 
part.  The  caustics  used  to  the  vagina  are  either  the  nitrate  of  silver, 
sulphate  of  copper,  or  alum,  all  in  stick  form.  A  conical  tampon  smeared 
with  vaseline  should  then  be  introduced  to  prevent  friction  of  the  cauter- 
ized spot  and  contact  with  sound  tissue. 

Special  Indications  for  Solid  Ajjplications. — Although  the  affections  in 
which  solid  substances  are  best  applied  to  the  cervix  and  vagina  have  been 
cursorily  refei'red  to  in  the  preceding  pages,  it  may  be  well  to  specify 
more  clearly  the  precise  conditions  in  which  they  alone  are  beneficial  or 
are  preferable  to  the  same  agents  in  solution. 

The  strong  caustics  or  escharotics,  such  as  caustic  potash,  chloride  of 
zinc,  and  chromic  acid  are  used  only  in  malignant  disease  of  the  cervix  or 
vagina,  when  it  is  desii'ed  to  destroy  the  diseased  tissue  to  its  very  core. 
The  caustic  potash  and  chloride  of  zinc  are  used  in  stick  or  pencils,  which 
are  bored  to  the  desired  depth  into  the  diseased  tissue  near  the  sound 


APPLICATIONS    THROUGH    THE    SPECULUM.  103 

border,  and  allowed  to  melt  there.  The  action  of  these  powerful  escha- 
rotics  should  be  confined  to  the  growth  by  protecting  the  sound  parts 
with  oil  or  lard  on  cotton,  or  by  cotton  soaked  in  a  solution  of  bicarbonate 
of  soda.  Chromic  acid,  not  being  deliquescent  like  potash,  does  not 
require  to  be  so  carefully  watched  against  spreading  ;  the  crystals  are 
simply  scattered  on  the  diseased  sui'face  and  soon  combine  with  the  secre- 
tions and  form  a  dry  eschai",  which  must  be  prevented  from  touching  ad- 
jacent parts  by  cotton  smeared  with  vaseline,  or  soaked  in  a  solution  of 
bicarbonate  of  soda.  As  a  rule,  it  is  more  convenient  to  employ  a  satu- 
rated solution  of  chromic  acid,  which  can  be  applied  with  an  applicator  or 
stick  wherever  desired.  The  nitrate  of  silver,  even  in  its  stick  form,  is  too 
superficial  a  caustic  to  be  of  any  great  avail  in  malignant  disease  ;  it  will 
barely  suffice  in  default  of  better.  It  has  been  the  great  remedy  for  all 
so-called  "  ulcei-ations  of  the  womb,"  and  has  done  its  full  share  of  harm. 
I  hardly  know  under  what  circumstances  I  should  employ  it,  if  I  had  one 
of  the  other  eqiially  efficient  and  (subsequently)  less  injurious  caustics  at 
hand.  I  shall  refer  later  on  to  the  dangers  and  limited  uses  of  the  solid 
lunar  caustic.  In  obstinate  papillary  erosions  of  the  cervix,  the  crystals  of 
chromic  acid  may  occasionally  remove  the  indolent  suppurating  sui'face 
and  set  up  healthy  reparative  action.  The  chloride  of  zinc  is  perhaps  the 
most  useful  and  reliable  escharotic  in  malignant  disease.  But  I  believe  I 
am  not  mistaken  when  I  say  that  at  present  the  extirpation  of  cervical  or 
vaginal  cancer  by  the  unaided  appU cation  of  these  powerful  escharotics 
has  been  abandoned.  Only  after  curette,  knife,  and  scissors  have  paved 
the  way  and  removed  the  bulk  of  the  growth,  is  the  escharotic  (usually  in 
solution)  employed  to  dispose  (so  far  as  it  can)  of  the  remains  of  the 
enemy. 

The  actual  cautery  is  used  in  the  same  class  of  cases  as  the  strong  es- 
charotics, viz.:  simple  and  papillary  erosion,  epithelioma  and  ulcerating 
carcinoma  of  the  cervix ;  also  in  aggravated  instances  of  chronic  endo- 
trachelitis  with  eversion  and  hyperplasia  of  the  lips.  Formerly,  it  was  cus- 
tomary to  apply  the  hot  iron  to  carcinoma  of  the  cervix  as  a  hemostatic 
without  previous  preparation;  the  effect  was  always  supei-ficial,  and  the 
result  generally  very  evanescent.  Now,  the  diseased  surface  is  thoroughly 
scraped,  and  as  much  pathological  tissue  removed  as  possible,  before  the 
heat  is  applied  ;  the  result  is  evidently  vastly  more  lasting,  especially  if 
the  iron  be  applied  at  red-heat,  so  as  to  extend  below  the  surface,  char  the 
deeper  parts,  and  produce  a  slough.  Such  applications,  either  of  heat  or 
escharotics,  require  to  be  repeated  at  greater  or  lesser  intervals  in  accord- 
ance with  the  rapidity  of  reproduction  of  the  vascular  mahgnant  granula- 
tions, and  .should,  as  at  first,  be  preceded  by  the  sharp  curette. 

I  have  frequently  applied  the  actual  cautery  in  one  form  or  another  to 
malignant  growths  of  the  cervix  uteri,  with  a  view  to  arresting  the  hemor- 
rhage and  retarding  the  progress  of  the  disease.  While  I  have  certainly 
succeeded  in  attaining  the  first  object,  I  have  failed  quite  as  markedly  in 
the  second  ;  indeed,  it  has  seemed  to  me,  almost,  that  the  growth  increased 
more  rapidly  after  cauterization,  and  sprouted  out  into  the  peri-uteiine 


164 


MINOR    GYNECOLOGICAL    MANIPULATIONS. 


cellular  tissue,  as  though  the  heat  stimulated  cell  proliferation.  At  aU 
events,  it  appeared  to  me  that  the  disease  remained  more  stationary  after 
the  use  of  escharotics,  and  for  a  time  at  least  was  confined  to  the  cervix. 
There  can  be  no  question  that  the  deeper  the  slough  produced  the  more 
beneficial  v^ill  the  application  be,  and  I  think  we  get  such  a  slough  from 
the  permanent  application  of  a  strong  escharotic  more  certainly  than  from 
the  actual  cautery. 

In  erosion  (simple  or  papillary)  of  the  cervix,  the  actual  cautery  is  an 
excellent  application.  Of  course  it  should  be  apphed  less  deeply  than  in 
malignant  disease,  since  but  a  very  superficial  slough  is  desired. 


Fig  88. — Galvano-cautery  Battery  of  Piffard,  and  Cautery  Instruments, 

It  is  of  extreme  importance  that  the  degree  to  which  the  cautery  is 
heated  be  carefully  regulated ;  for  a  caustic  escharotic  effect,  when  a  deep 
slough  and  wide-spreading  reaction  is  desired,  the  red  or  even  white  heat 
is  reqiiired  ;  but  when  a  styptic  or  merely  astringent  action  is  intended, 
the  iron  should  be  at  black  heat  only. 

There  are  three  varieties  of  apparatus  by  which  the  actual  cautery  may 
be  applied :  the  old-fashioned  cautery  irons  of  different  shapes  and  pat- 
terns, the  galvano-cautery,  and  the  thermo-cautery  of  Paquelin.  A  very 
simple  and  mild  thermic  effect  may  be  produced  by  applying  the  melted 
end  of  a  stick  of  sealing-wax  to  the  diseased  surface  ;  for  want  of  better, 
this  expedient  may  be  used  in  simple  erosion  of  the  cervix.     The  cautery 


APPLICATIOTTS    THROUGH   THE    SPECULUM. 


165 


ii-ons  are  of  clifiFerent  shapes  and  sizes,  according  to  the  extent  of  the  sm-- 
face  to  be  touched ;  thus  we  have  them  with  a  round  flat  tip,  or  button,  an 
oKve,  or  a  slender  point,  the  button  and  olive  being  the  most  common. 
The  iron  is  fastened  in  a  convenient  handle  of  wood.  These  irons  are 
heated  by  simple  immersion  in  a  fire  or  flame.  The  metal  of  the  cautery 
tips  in  the  galvano-cautery  apparatus  is  platinum,  the  shape  of  the  tip 
being  generally  that  of  a  spiral  cone  of  wire,  although  a  knife-shaped  tip 
is  used  when  a  portion  of  tissue  is  to  be  removed.  The  thermo-cautery 
apparatus  of  Paquelin  is  a  recent  invention,  and  has  rapidly  grown  in  favor 
for  short  operations,  almost  supplanting  the  galvano-cautery  by  its  porta- 
bility and  convenience.  It  consists  of  a  tip  of  platinum  (of  various  shapes) 
which  is  heated  by  a  flame  of  benzine  blown  upon  it  from  the  handle, 
by  means  of  a  rubber  balloon  and  tube  attached  to  it.  The  button- 
shaped  tip  is  the  one  ordinarily  used  to  cauterize  a  flat  or  hollow  sur- 


FlG.  89. — Paquelin's  Thermo-cautery  Apparatus  with  Wilson's  Antithermic  Shield. 


face ;  the  pointed  tips  to  perforate  deep-seated  abscesses  in  the  broad  liga- 
ment, or  cauterize  the  cervical  canal,  the  knife  to  remove  a  portion  or  the 
whole  of  the  cervix,  etc.  The  platinum  tip  requires  to  be  heated  to  a  red 
heat  in  a  spirit-lamp,  when  the  benzine  vapor  is  blown  into  it  and  ignites. 
The  compi*ession  of  the  rubber  bulb  keeps  the  platinum  at  the  required 
degree  of  heat.  For  the  jourpose  of  protecting  the  neighboring  parts 
from  the  radiating  heat  in  long  operations  on  the  cervix,  chiefly  ampu- 
tation, a  very  ingenious  contrivance  has  recently  been  devised  by  Dr.  H.  P. 
C.  Wilson,  of  Baltimore,  which  consists  of  a  hollow  metal  shield  for  the 
cautery  shaft  and  tip,  through  which  shield  a  current  of  cold  water  is  kept 
running  by  means  of  an  Eguisier's  irrigator  at  one  end,  and  an  exit-tube 
at  the  other.  The  accompanying  cut  gives  a  good  representation  of  the 
"  antithermic  shield,"  as  its  inventor  calls  it,  and  its  attachment  to  the 
cautery.  In  long  operations  which  must  be  performed  through  Sims' 
speculum,  this  protective  is  indispensable  ;  for  mere  styptic  or  escharotic 
applications  of  the  cautery,  which  may  be  made  through  any  form  of  specu- 


166  MITSrOR    GYNECOLOGICAL    MANIPULATIOlSrS. 

lum  which  exposes  the  diseased  part,  no  such  addition  is  ueeded.  I  have 
always  used  the  Sims  speculum  ;  but  a  large  tubular  speculum,  or  a  widely 
expanded  bivalve,  will  answer  very  weU  when  only  a  momentary  caustic 
application  is  intended.  Tubes  of  horn  have  been  constructed  for  this 
purpose,  but  the  hard  rubber  is  almost  as  good  a  non-conductor  of  heat ; 
When  the  application  is  momentary,  however,  an  ordinary  glass  tube  will 
do,  since  the  application  is  too  short  to  crack  the  glass. 

After  the  application  of  the  cautery  to  the  cervix,  a  cleansing  injection 
should  be  made  through  the  speculum  to  remove  all  debris,  and  protect- 
ive tampons,  smeared  with  vaseline  applied.  If  the  cautery  was  used 
as  a  hemostatic,  it  is  advisable  to  tampon  the  vagina  tightly  with  flat 
cotton  disks  (as  hereafter  to  be  described),  since  unexpected  separation  of 
the  eschar  and  violent  secondary  hemorrhage  might  take  place.  It  is  also 
well  to  be  on  the  safe  side  and  to  tampon  the  vagina  again  tightly  after 
removing  the  first  set  at  the  end  of  forty-eight  hours,  since  secondary- 
hemorrhage  may  occur  at  any  time  within  a  week  or  longer  after  the  first 
cauterization.  A  single  sad  instance  has  forcibly  fixed  the  utility  of  this 
precaution  in  my  memory.  I  lost  a  patient  from  secondary  hemorrhage 
seventy  hours  after  curetting  and  searing  the  cancerous  cervix  with  Paque- 
lin,  the  hemorrhage  not  appearing  until  after  I  had  removed  the  first 
light  tampons  and,  finding  the  stump  absolutely  bloodless,  had  merely  in- 
serted a  few  lightly  packed  tampons.  I  do  not  beheve  that  in  this  case 
any  form  of  tamponade  could  have  prevented  or  checked  the  bleeding, 
which  was  frightful,  the  slough  having  apparently  ojoened  not  only  the 
circular  artery  but  also  the  large  pampiniform  veins.  But  this  danger  of 
the  slough  possibly  extending  deeper  than  was  intended  obtains  in  every 
cauterization,  and  hence  the  precautionary  tamponade. 

The  cautery  is  attended  by  so  little  pain,  and  is  so  rapid,  that  it  is  un- 
necessary, for  that  reason  alone,  to  give  an  anesthetic.  It  is  only  when 
the  patient  is  veiy  timorous  or  restless,  and  the  preparations  inevitable  to 
the  starting  of  the  cautery  (heating  of  the  irons,  connection  of  the  current, 
heating  of  the  tip,  and  blowing  of  the  benzine  flame),  or  the  hissing  noise 
produced  by  the  contact  of  the  cautery  with  the  flesh,  frighten  her,  that 
it  is  advisable  to  anesthetize  her.  The  dangers  of  the  operation  consist  in 
secondary  hemorrhage  and  the  production  of  inflammatory  reaction  in  the 
parametrium.  Of  the  former  I  have  just  spoken  ;  the  latter  result  I  have 
never  known  to  occur  after  the  styptic  or  escharotic  application  of  the 
actual  cautery.  Generally  it  is  not  necessary  to  confine  the  patient  to  her 
bed  ;  if  she  is  so  confined  for  twenty-foui'  hours  or  longer,  it  is  not  be- 
cause of  the  cautery,  but  of  the  curetting  or  other  operation  which  pre- 
ceded the  cautery.  As  a  rule,  the  employment  of  a  dull,  scarcely  red  heat, 
and  a  very  slow  operation,  will  generally  obviate  the  danger  of  secondary 
hemorrhage.     Its  further  consideration  is  beyond  my  present  plan. 

After-treatment. — The  after-treatment  of  a  cauterized  cervix  after  the 
slough  has  separated  and  the  danger  from  secondary  hemorrhage  is  past, 
consists  in  tepid,  mildly  disinfectant  injections  until  granulation  is  estab- 
lished (once  or  twice  daily,  care  being  taken  to  insert  the  nozzle  of  the 


APPLICATIONS    THROUGH    THE    SPECULUM.  167 

syringe  only  just  within  the  vaginal  orifice,  in  order  not  to  accidentally 
excite  bleeding),  and  later  in  mildly  astringent  injections  (sulphate  or 
chloride  of  zinc,  alum,  etc.)  until  the  surface  has  cicatrized  over  and  all 
discharge  ceased. 

Precautions. — In  applying  the  solid  stick  of  nitrate  of  silver  to  the  cer- 
vix, it  should  be  borne  in  mind  that  its  thorough  or  too  frequent  use  is 
almost  invariably  followed  by  cicatricial  contraction  of  the  external  os  and 
cicatricial  toughening  of  the  mucous  membrane  covering  the  cervix.  The 
stick  of  nitrate  of  silver  should,  therefore,  be  emjoloyed  only  in  cases 
where  the  external  os  is  patulous  and  abnormally  large,  where,  indeed,  its 
contraction  is  desired  ;  in  all  cases  with  normal  or  small  os  the  milder 
solutions  of  the  nitrate  are  to  be  preferred  ;  indeed,  the  stick  should  never 
be  used  until  the  solutions  have  failed,  and  even  then  the  superficial  ap- 
plication of  nitric  acid,  as  hereafter  to  be  described,  is  advisable  before 
resorting  to  the  solid  silver-nitrate.  This  fear  of  cicatricial  contraction 
following  the  stick  may  be  exaggerated  ;  but  competent  observers  support 
my  experience  that  many  a  utero-ovarian  neui-algia,  with  consequent  gen- 
eral malnutrition,  many  a  dysmenorrhea  and  sterility,  has  been  produced 
solely  by  the  inclusion  of  nerve-filaments  in,  and  the  stenosis  of  the  ex- 
ternal OS  by  the  cicatricial  tissue  of  solid  nitrate  of  silver  api^lications  to 
the  cervix  for  "  ulceration  of  the  womb."  The  modern  gynecologist  of 
experience  has  learned  to  use  the  silver  stick  to  the  cervix  only  when  he 
wants  cicatrix  and  contraction  ;  and  even  then  he  finds  that  contraction 
is  much  more  easily  procurable  by  paring  the  edges  of  the  os  and  unitin"" 
them  by  sutures.  The  formation  of  cicatricial  tissue  on  the  cervix  he 
avoids,  for  he  knows  that  it  may  prove  the  source  of  local  and  general 
trouble,  even  though  it  may  not,  except  in  aggravated  cases,  produce 
such  marked  general  anemia  as  Emmet  claims,  I  can  frankly  say  that, 
while  I  always  carry  the  stick  of  nitrate  of  silver  in  a  long  vaginal  porte- 
caustique  in  my  gynecological  satchel,  I  do  not  recollect  using  it  for  sev- 
eral years,  except  in  one  case  of  chancroid  of  the  cervix,  in  the  absence  of 
nitric  acid,  which  I  subseqiiently  applied,  and  in  the  worst  case  of  cervical 
catarrh  which  I  have  seen.  So  beneficial  and  indisiDensable  as  are  the 
solutions  of  different  strength  of  the  nitrate  of  silver  in  the  treatment  of 
inflammatory,  desquamative,  and  ulcerative  affections  of  cervix  and  vagina, 
so  injurious  and  reprehensible  is  the  solid  stick.  It  was  the  sheet-anchor 
of  the  gynecologist  of  the  past,  and  it  has  done  vastly  more  harm  than 
good.  The  substitution  of  a  dense  cicatricial  surface  for  a  soft,  granulat- 
ing, secreting  erosion  is  but  a  poor  exchange  ;  the  bad  effects  are  gener- 
ally not  felt  until  long  after  the  patient  has  been  discharged  "  cured." 

A  W'Ord  of  caution  should  also  be  spoken  against  the  use  of  chi'omic 
acid  in  crystals  or  strong  solutions.  In  some  persons  of  unusual  suscep- 
tibility it  is  very  rapidly  absorbed  and  produces  unpleasant  nervous 
shock,  vomiting,  and  diarrhea.  I  once  met  with  such  an  effect  in  a  case 
of  carcinoma  of  the  cervix,  to  which  I  applied  a  saturated  solution  of 
chromic  acid  after  scraping  away  the  bleeding  granulations  with  the 
curette.     The  peculiar  dry,  burning  sensation  in   the  fauces  was  expe- 


168  MINOIl    GYNECOLOGICAL    MANIPULATIONS. 

rienced  in  less  than  ten  minutes,  shock  and  collapse,  vomiting  and  dian-hea 
soon  followed,  and  for  several  days  the  patient  was  severely  ill.  The  ap- 
plication should,  therefore,  be  superficial,  and  all  excess  of  acid  be  at  once 
removed. 

/?.   Fluids. 

The  medicinal  agents  which  are  employed  in  a  fluid  form,  either  in 
their  natural  chemical  state  or  in  solutions  of  various  strength,  to  the  cer- 
vix and  vagina  are:  Escharotics :  Nitric  acid,  chromic  acid,  bi'omine,  acid 
nitrate  of  mercur-y,  saturated  solution  of  chloride  of  zinc.  Caustics:  Ni- 
trate of  silver,  carbolic  acid,  iodized  phenol  (carbolic  acid  and  tincture  of 
iodine,  equal  parts),  pyroligneous  and  acetic  acid.  Astringents  and  styp- 
tics :  Tincture  of  chloride  of  iron,  Monsel's  solution  of  the  persuljphate  of 
iron,  solution  of  tannin  in  glycerine,  mixture  of  bismuth  and  glycerine, 
decoctions  of  oak  and  willow  bark  (all  containing  tannin),  fluid  extract  of 
pinus  and  hydrastis  Canadensis,  and  of  eucalyptus  globulus,  strong  solu- 
tion of  alum,  acetate  of  lead,  of  sulphate  of  zinc  or  copper,  saturated  so- 
lution of  resin  in  alcohol  (James'  styptic),  simple  vinegar.  Alteratives: 
Tincture  of  iodine,  solution  of  iodide  of  potash,  solution  of  iodofonn  in 
glycerine,  cantharidal  collodion.  Hydragogue :  Glycerine.  Emollients: 
Oil  of  olives  or  poppies.  Narcotics:  Tincture  of  opium,  belladonna,  co- 
nium,  or  hyoscyamus,  solution  of  hydrate  of  chloral,  saturated  solution  of 
the  bromides  of  potash,  ammonium,  or  sodium.  Disinfectants :  Corrosive 
subhmate,  carbolic  acid,  boracic  acid,  chlorinated  soda,  thymol. 

Manner  of  Using  and  Special  Indications. 

According  to  the  effect  desired  these  agents  are  left  in  contact  with 
the  diseased  surface  for  a  shorter  or  longer  period.  As  a  rule,  powerful 
substances,  like  the  escharotics,  then,  agents  which  act  instantaneously 
like  caustics,  and  the  effect  of  which  is  not  increased  by  longer  contact, 
are  only  applied  for  an  instant,  and  then  removed  or  their  excess  neutral- 
ized. Astringents,  styptics,  emolHents,  especially  alteratives,  hydragogues, 
and  narcotics,  on  the  other  hand,  require  to  remain  in  contact  with  the 
part  for  a  period  varying  from  several  minutes  to  twenty-four  hours,  in 
order,  to  exert  their  full  effect.  These  latter,  therefore,  are  best  applied 
on  a  convenient  vehicle,  which,  in  gynecological  practice,  is  represented 
by  a  pad  or  roU  or  ball  of  cotton,  known  under  the  name  of  tampon,  the 
varieties,  uses,  and  indications  of  which  will  be  described  at  length  in  the 
chapter  on  Tamponade  of  the  Vagina. 

Fluids  may  be  applied  through  either  of  the  three  varieties  of  specula, 
but  it  is  for  this  purpose  that  the  tubular  speculum  may  be  said  to  offer 
special  advantages,  and  for  this  only.  I  have  for  years  employed  the 
tubular  speculum  solely  for  the  purpose  of  applying  fluids  to  the  vagina, 
using  the  bivalve  and  Sims  for  that  purpose  only  in  the  case  of  applica- 
tions of  tincture  of  iodine  to  the  vaginal  vault.  Ointment  and  powders, 
when  conveyed  on  the  surface  of  tampons,  can  be  equally  weU  applied 
through  either  of  the  three  specula.     Strong  fluid  escharotics  are  best  ap- 


APPLICATIONS    THROUGH    THE    SPECULUM.  169 

plied  to  tlie  cervix  through  a  cyHnder,  if  the  cervix  be  not  too  large  to  en- 
ter the  speculum,  or  the  vagina  too  small  to  admit  a  sufficiently  large  tube, 
for  the  reason  that  the  escharotic  is  less  liable  to  touch  the  sound  tissue 
than  if  applied  through  a  speculum  which  exposes  the  vagina  also  ;  this  is 
particularly  true  of  a  diffusable  escharotic  like  caustic  potash.  However, 
as  will  be  described  hereafter,  it  is  easy  to  protect  the  sound  tissues  by 
covering  them  with  cotton  ;  and  I  am  in  the  habit  of  applying  escharotics 
to  the  cervix  through  the  Sims  speculum  held  by  my  nurse. 

In  order  that  I  may  cover  the  subject  comj)letely,  and  that  no  point 
of  practical  importance  be  overlooked,  I  will  proceed  to  describe,  in  de- 
tail, the  application  of  each  of  the  fluid  agents  above  named,  even  at  the 
risk  of  occasional  repetition.  In  default  of  practical  experience  in  these 
minute  technicalities,  the  only  means  of  affording  the  practitioner  the 
opportunity  to  become  acquainted  with  them,  and  to  avoid  annoyance  to 
himself  and  pain  to  the  patient,  is  to  give  him  a  description  so  minute  as 
to  enable  him  to  see,  in  his  mind's  eye,  every  step  of  the  various  methods 
employed  in  minor  gynecological  therapeutics. 

This  must  be  my  excuse,  if  at  times  in  these  pages  I  seem  prolix  and 
trivial.  Only  the  practitioner  who  has  been  obliged  to  discover  these  lit- 
tle devices  and  "knacks  and  dodges,"  one  by  one,  at  the  expense  of  time 
and  annoyance  to  himself  and  discomfort  to  the  patient,  will  apj)reciate 
that  they  are  by  no  means  trivial  or  unimportant  to  the  successful  practice 
of  gynecology.  A  physician  who  has  once  burned  the  labia  of  a  patient 
with  iodine,  or  worse  yet,  with  carbolic  or  nitric  acid,  because  he  had  not 
learned  the  precise  manner  by  which  to  avoid  such  an  accident  (and  such 
knowledge  does  not  come  by  intuition)  will  realize  how  necessary  it  is  to 
know  even  the  most  trifling  points  in  these  matters. 

EscHAEOTics. — Of  these  agents  the  nitric  acid  is  undoubtedly  the  one 
most  commonly  used.  They  are  all  applied  to  the  cervix  alone,  to  the  va- 
gina only  when  the  same  condition  exists  there  which  called  for  their  ap- 
plication to  the  cervix,  viz.,  malignant  disease  (epithelioma). 

Venereal  warts  on  the  cervix  or  in  the  vagina,  so-called  "  acute  con- 
dylomata," should  be  touched  with  fuming  nitric  or  saturated  solution  of 
chromic  acid,  which  will  cause  them  to  shrivel.  In  this  connection,  I  may 
■state  that  Dr.  Piffard,  of  New  York,  reports  the  speedy  disappearance  of 
these  growths  under  the  combined  local  and  constitutional  use  of  fluid 
extract  of  thuya  occidentaUs  (tamarack) ;  the  warts  are  painted  every  day 
with  the  pure  fluid  extract,  a  wash  or  injection  of  the  same,  one  drachm 
to  the  pint,  is  ordered,  which  is  also  to  be  applied  on  cloths  continually 
if  the  warts  are  external,  and  twenty  drops  of  the  extract  are  given  inter- 
nally ter  die. 

A  saturated  solution  of  chi'omic  acid  in  water  (or  it  may  be  diluted  as 
appears  advisable),  a  solution  of  bromine  in  alcohol  1  :  5  or  10,  a  satu- 
rated solution  of  the  pernitrate  of  mercury,  are  generally  employed  in 
malignant  disease  only.  Formerly  the  solution  of  the  nitrate  of  mer- 
cury was  much  used  by  gynecologists  in  the  treatment  of  so-called  "ul- 
ceration of  the  neck  of  the  womb  ; "  but  since  we  have  learned  through 


170  MINOK    GYNECOLOGICAL    MANIPULATIONS. 

Emmet  that  "ulceration"  is  in  the  large  majority  of  cases  due  to  tlie 
aversion  of  the  mucous  membrane  of  the  cervix  through  an  unhealed 
puerperal  laceration  of  that  part,  the  red  everted  cervical  mucosa  simu- 
lating an  ulcer,  we  have  recognized  that  the  conversion  of  the  normal  or 
merely  hyperplastic  and  slightly  eroded  mucous  surface  into  a  dense  cica- 
trix is  not  the  proper  way  of  healing  this  affection  ;  and  the  progressive 
part  of  the  profession  have  ceased  applying  strong  escharotics  to  these 
cases,  except  in  unusual  hyperplasia  of  the  cervix.  In  the  comparatively 
rare  cases  of  superficial  epithelial  erosion  of  the  cervix,  especially  if  asso- 
ciated with  papillary  or  follicular  hypertrophy,  the  pernitrate  or  chromic 
acid  solution  may  be  used  with  advantage ;  but  generally  the  pure  nitric 
acid  will  suffice,  and  it  will  often  do  good  in  superficial  ej)ithehal  cancer 
of  the  cervix.  The  supei-ficial,  merely  astringent,  application  of  strong 
nitric  acid  to  the  hyperplastic,  suppurating,  everted  mucous  membrane  of 
a  lacerated  cervix  will  often  do  great  good  by  constricting  the  tissues  and 
preparing  them  for  the  operation  of  tracheloplasty. 

The  strong  escharotics  must  be  applied  only  at  certain  intervals,  vary- 
in""  in  accordance  with  the  rapidity  of  sej)aration  of  the  slough  and  the 
necessity  for  a  repetition  of  the  cauterization ;  generally  not  oftener  than 
once,  or  at  most,  twice  a  month.  If  appHed  only  superficially  with  a 
stick,  nitric  acid  may  be  repeated  every  week  until  improvement  ensues ; 
but  if  the  application  be  so  deep  as  to  produce  a  slough,  the  same  rule 
applies  as  to  the  other  escharotics.  If  the  escharotic  (which  in  such 
cases  should  be  only  the  nitric  or  dilute  chromic  acid)  is  applied  to  a 
superficial  ulceration  of  the  cervix,  it  is  desirable  to  avoid  the  formation 
of  a  deep  slough  and  consequent  cicatricial  tissue  ;  such  applications 
should,  therefore,  be  merely  momentary,  be  made  with  an  absorbent  sub- 
stance, as  a  wooden  stick,  and  should  not  be  repeated  oftener  than  once 
or  twice  at  intervals  of  two  to  four  weeks.  When,  on  the  other  hand,  it 
is  intended  to  destroy  as  much  of  the  cer^ax  as  possible  [e.g.,  in  malig- 
nant disease),  the  ajpplications  of  the  escharotic  should  be  not  only  thor- 
ough and  long-continued,  with  an  excess  of  the  agent,  but  repeated  as 
soon  as  the  slightest  evidence  of  the  return  of  the  disease  shows  itself. 
The  strength,  frequency,  and  thoroughness  of  these  applications  must,  as 
in  every  therapeutical  measure,  be  regulated  by  the  peculiarities  and  exi- 
gencies of  each  individual  case,  and  can  be  learned  only  by  experience. 

If  the  cervix  or  diseased  part  of  it,  or  the  vagina,  can  be  conveniently 
exposed  through  the  cyhndrical  speculum,  this  is  unquestionably  the  most 
convenient  method  of  applying  the  escharotic.  A  stick  of  hard  rubber, 
twelve  inches  in  length,  and  with  a  screw-spiral  at  its  smaller  end  (see  Fig. 
87),  is  a  convenient  instrument  for  aU  fluid  applications.  A  bit  of  ab- 
soi'bent  cotton  is  tightly  wrapped  about  the  screw  end  (in  case  of  an  escha- 
rotic very  tightly  so  as  not  to  absorb  too  much  fluid  ;  in  milder  agents  only 
tightly  enough  to  prevent  its  slipping  off)  and  dipped  into  the  fluid  ;  when 
sufficient  has  been  taken  up  it  is  carried  through  the  speculum  against  the 
cervix  and  the  whole  diseased  surface  thoroughly  mopped  with  it.  If  the 
sui-face  bleeds  very  readily,  the  stick  should  merely  be  pressed  against  it, 


APPLICATIONS    THEOtJGH    THE    SPECULUM.  I7l 

not  rapidly  moved,  so  as  not  to  excite  hemorrhage.  Eveiy  nook  and 
crevice  of  the  diseased  surface  should  be  thoroughly  touched  and  the  stick 
passed  as  far  up  into  the  cervical  canal  as  may  appear  desirable,  in  any 
case  stopping  short  of  the  internal  os,  unless  the  special  indication  exists 
for  the  cauterization  of  the  uterine  cavity,  which  procedure  requii'es 
other  preparations  and  will  be  discussed  later  on.  If  it  aj^pears  necessary, 
the  stick  may  be  dipped  again  into  the  fluid  and  the  cauterization  re- 
peated, until  a  sufficiently  deep  eschar  seems  to  have  been  formed.  All 
excess  of  fluid  should  then  be  mopped  up  on  absorbent  cotton  carried  in 
by  long  uterine  dressing-forceps.  If  a  very  thorough  eft'ect  is  desired  it 
is  best  not  to  neutralize  the  excess  of  fluid  by  an  alkaline  solution  ;  if  the 
effect  is  to  be  but  sujjerficial,  as  should  always  be  the  case  in  simple  ero- 
sion of  the  cervix,  such  neutralization  is  always  indicated,  and  can  be  ob- 
tained by  introducing  a  solution  of  bicarbonate  of  soda  or  simj)le  water 
into  the  speculum  by  a  syringe,  or  on  cotton  by  forceps  ;  the  excess  of 
water  is  caught  in  a  cup  as  it  flows  out  of  the  speculum.  It  should  be 
well  understood  that  when  such  a  supei'ficial  effect  only  is  desired,  the  es- 
charotic  should  not  be  conveyed  on  a  cotton-wrapped  stick,  but  on  an  ab- 
sorbent wooden  stick  which  takes  up  all  excess  of  the  fluid  (such  as  a 
match  held  in  the  dressing-forceps).  "When  the  cauterized  surface  has 
been  wiped  dry,  a  tampon,  covered  with  vaseline  or  sweet-oil,  or  common 
lard,  is  introduced  through  the  speculum  and  held  gently  but  firmly 
against  the  cervix  with  the  closed  dressing-forceps,  while  the  speculum  is 
rotated  and  withdrawn.  This  tampon  is  to  be  removed  by  the  string  at- 
tached to  it  in  twenty-four  hours,  and  tepid  injections,  perhaps  with  the 
addition  of  carbolic  acid  (one  per  cent.),  made  once  or  twice  a  day  until 
the  slough  separates.  A  specular  examination,  made  at  intervals  of  three 
to  four  days,  will  disclose  this  occurrence,  which  generally  calls  for  the 
occasional  application  of  some  mild  caustic  or  astringent  solution  (as 
solution  of  nitrate  of  silver,  sulphate  of  zinc,  or  tannin  and  water  or  glycer- 
ine) as  hereafter  to  be  described,  until  the  surface  has  completely  healed 
over.  These  rules  apply  equally  to  a  malignant  ulcei-ation,  in  which  only 
temporary  relief  is  expected,  and  to  superficial  erosion  in  which  a  com- 
plete and  permanent  cure  is  aimed  at.  Of  all  these  agents  the  pure  nitric 
acid  and  the  saturated  solution  of  the  chloride  of  zinc,  while  the  most  sui*e 
and  efficacious,  are  at  the  same  time  the  least  injurious. 

For  it  should  be  remembered  that  the  toxic  effects  of  two  of  these 
remedies,  the  chromic  acid  and  the  pernitrate  of  mercury,  may  not  be  con- 
fined to  the  local  destruction  of  the  diseased  tissue  :  the  chromium  and 
the  mercury  may  be  absorbed  and  produce  severe  constitutional  symp- 
toms ;  the  chromium,  collapse,  vomiting,  and  purging ;  the  mercury, 
salivation.  Care  should  therefore  be  taken  not  to  continue  the  application 
of  these  two  agents  too  long  or  too  thoroughly,  and  to  remove  all  excess 
as  soon  as  the  cauterization  is  accomplished.  While  the  chloride  of  zinc 
acts  best  if  applied  on  wads  of  cotton  soaked  in  the  solution  (saturated  or 
equal  parts)  squeezed  dry  and  kept  in  apposition  to  the  diseased  surface 
for  three  or  four  days,  the  chromic  acid,  bromine,  and  mercury  are  best 


172  MINOR    GYNECOLOGICAL    MANIPULATIONS. 

applied  merely  as  above  directed,  the  excess  neutralized  and  the  spread 
prevented  by  oiled  tampons.  The  chloride  of  zinc  is  generally  applied  on 
cotton  wads,  as  just  described,  after  the  curetting  or  excision  of  cancerous 
tissue  from  the  cervix  uteri.  The  wads  must  be  squeezed  thoroughly 
dry,  and  are  packed  tightly  with  the  forceps  into  the  cavity  left  by  the 
excised  growth.  To  prevent  any  possible  oozing  on  and  cauterization 
of  sound  tissue,  the  vagina  is  previously  sponged  out  with  a  saturated 
solution  of  bicarbonate  of  soda  and  subsequently  filled  with  tampons 
soaked  in  this  solution.  In  this  manner  all  excess  of  the  zinc-chloride  is 
neutralized. 

The  danger  of  leaving  the  strong  chromic  acid  solution  in  prolonged 
contact  with  the  diseased  surface  in  this  manner  has  already  been  illus- 
trated while  speaking  of  the  application  of  solid  substances  to  the  cervix. 
The  slovigh  from  these  escharotics  generally  separates  in  a  week ;  that  of 
chloride  of  zinc,  chromic  acid,  and  bromine  is  dry,  that  of  nitric  acid 
usually  soft  and  moist.  No  effort  should  be  made  to  detach  the  slough 
by  force,  other  than  such  as  the  vaginal  injections  exert. 

A  possible  danger  during  the  separation  of  the  slough  of  an  escharotic 
should  be  mentioned,  viz.,  the  chance  erosion  of  a  blood-vessel  and  severe 
hemorrhage.  Directions  (such  as  introduction  of  cotton,  pressing  an 
abundance  of  cotton  against  the  vulva,  keeping  the  thighs  together,  ele- 
vated hips,  low  head,  etc.),  should  therefore  be  left  with  the  attendants,  in 
case  such  a  hemorrhage  should  suddenly  occur  and  its  possibility  be  pro- 
vided for  by  the  physician.  The  manual  compression  of  the'  abdominal 
aorta  through  the  abdominal  wall  or  the  rectum  should  be  borne  in  mind 
by  the  physician  as  a  means  which  may  possibly  alone  arrest  the  hemor- 
rhage in  such  a  case.  Such  hemorrhages  may  at  times  be  very  profuse, 
especially  if  the  escharotic  has  been  carried  up  into  the  cervical  canal.  The 
solid  or  pulverized  agents  are  more  hable  to  be  followed  by  deep  slough- 
ing and  hemorrhage  than  fluids. 

The  directions  given  above  apply  equally  to  the  use  of  the  fluid  es- 
charotics through  a  bivalve  or  Sims'  speculum.  But  additional  precau- 
tions should  be  observed  to  protect  the  sound  parts  from  the  caustic  by 
packing  cotton,  best  soaked  in  solution  of  bicarbonate  of  soda  and  squeezed 
dry,  underneath  the  cervix  so  as  to  catch  any  fluid  which  may  flow  from 
the  diseased  surface.  Or,  the  cotton  may  be  soaked  in  sweet-oil  or  cov- 
ered with  lard.  This  cotton  is  snugly  packed  under  the  cervix  with 
dressing-forceps.  If  the  escharotic  is  applied  on  an  absorbent  wooden 
stick,  it  is  generally  unnecessary  to  thus  protect  the  sound  parts. 

At  the  present  day  our  knowledge  of  the  benefit  to  be  derived  by 
scraping  away  the  exuberant  cancerous  granulations  with  a  sharp  scoop, 
and  of  our  inability  to  safely  destroy  the  whole  disease  by  even  the  most 
powerful  escharotics,  renders  it  unnecessary  to  use  agents  which  will  pro- 
duce sloughs  the  extent  of  which  cannot  be  foreseen.  The  use  of  the 
acid  pernitrate  of  mercury  and  of  caustic  potash  in  cancer  of  the  cervix 
uteri  has  therefore  been  abandoned  by  the  majority  of  gynecologists,  and 
only  those  escharotics,  like  the  chloride  of  zinc,  bromine,  chromic  and 


APPLICATIONS    THROUGH    THE    SPECULUM.  173 

nitric  acids,  liave  been  retained,  the  effect  of  which  can  be  better  esti- 
mated and  controlled. 


Caustics  ;  Astringents  and  Styptics  ;  Alteratives  ;  Hydrayogue  ;  Emollients  ; 

Narcotics. 

I  have  grouped  all  these  classes  of  fluid  remedial  agents  together  be- 
cause, being  milder  in  their  character,  they  are  all  introduced  against  the 
cervix  or  vagina  in  very  much  the  same  manner,  viz.,  by  being  poured  into 
a  cylindrical  sj)eculum  or  applied  on  cotton  tampons  left  in  situ  for  several* 
hours  or  longer. 

For  the  application  of  fluids  of  milder  character,  the  cylindrical  specu- 
lum is  the  instrument.  Not  only  that  it  permits  the  touching  of  the  cer-' 
vix,  for  this  can  be  done  equally  well  and  safely  through  the  bivalve  and 
Sims,  but  chiefly  because  its  tubular  form  allows  the  fluid  to  be  introduced 
more  conveniently  and  brought  in  contact  ^vith  every  portion  of  the  va- 
ginal surface,  by  simply  pouring  a  sufficient  quantity  into  the  speculum 
and  successively  bathing  the  whole  canal  in  the  fluid.  This  is  done  by 
gently  rotating  and  withdrawing  the  speculum  while  a  cotton-wrapped 
stick  distributes  the  agent  against  every  portion  of  the  vaginal  mucous 
membrane  until  the  speculum  is  almost  withdrawn  from  the  vagina.  The 
tube  is  then  gently  reintroduced  up  to  the  ceiwix,  and  the  fluid  contained 
in  it  emptied  into  a  cup  by  gently  depressing  the  mouth  of  the  speculum. 
A  tampon  soaked  in  glycerine,  or  smeared  with  vaseline  or  some  other 
emolhent,  is  then  introduced  nearly  to  the  cervix  and  the  speculum  with- 
drawn. If  it  is  desirable  to  cover  the  tampon  with  a  medicinal  substance, 
such  as  an  astringent  powder  or  solution,  in  addition  to  the  agent  intro- 
duced by  the  speculum,  the  tampon  ^  can  be  introduced  quite  as  well 
through  the  tube  as  through  a  Sims  or  bivalve.  Or  the  powder  may  be 
sjorinkled  into  the  tube  and  retained  by  a  tampon,  as  already  described. 

Some  of  the  stronger  fluid  caustics  and  astringents  are  not  generally 
poured  into  the  speculum  as  described,  but  being  used  chiefly  as  applica- 
tions to  the  cervix  are  applied  directly  to  the  diseased  spot  by  a  cotton- 
wrapped  stick  ;  these  are  piu-e  carbolic  acid,  iodized  phenol,  pyrohgneous 
and  acetic  acids,  pure  tincture  of  chloride  of  iron,  and  solution  of  persul- 
phate of  iron,  saturated  solution  of  alum,  and  copper  and  zinc  sulphate. 
Others  again,  being  iiitended  to  remain  long  in  contact  with  the  jDart  for 
which  they  are  specially  designed,  are  applied  on  the  end  of  or  in  the  sub- 
stance of  cotton  tampons  ;  such  are  the  majority  of  the  other  agents  men- 
tioned in  the  list.  Generally,  however,  the  fluid  is  first  brought  in  con- 
tact with  the  vaginal  interior  by  being  poured  into  the  speculum  (which 
doubtless  is  the  more  effectual  method)  and  the  effect  assured  by  intro- 
ducing a  tampon  saturated  in  the  same  fluid.  These  tampons  are  allowed 
to  remain  from  twelve  to  twenty-four  hours,  and  their  removal  is  gener- 
ally followed  by  the  cleansing  of  the  vagina  by  some  mild  astringent  in- 
jection or  by  the  hot  vaginal  douche,  as  already  described.  The  repetition 
of  these  applications  depends  entirely  upon  the  gravity  of  the  case  and 


174  MIXOPv    GYNECOLOGICAL    MAISTIPULATIOITS. 

tlie  judgment  of  the  physician.     The  average  frequency  will  be  stated 
under  each  sej)arate  agent. 

Caustica. — I  have  already  stated  that  four  of  the  five  caustics  included 
in  my  list,  \iz.,  pure  carbolic  and  acetic  acid,  the  iodized  phenol,  and  pyro- 
Hgneous  acid,  are  too  jDOwerful  to  be  applied  indiscriminately  to  the 
cervix  and  vagina,  and  that  their  use  is  limited  to  conditions  of  certain 
portions  of  these  organs  in  which  a  positive  caustic  effect  is  desired  ;  to 
these  parts  the  caustic  is  applied  by  means  of  a  cotton-wrajjped  stick,  and 
the  excess  at  once  removed,  as  prescribed  for  escharotics. 

The  indications  for  these  strong  caustics  are  chiefly  erosions  of  the 
cervix  and  lips  of  the  external  os,  in  which  the  papillae  and  areolar  tissue 
are  more  or  less  hj^Derplastic,  the  blood-vessels  dilated,  and  the  reparative 
power  impaired.  The  stimulus  of  these  active  agents  sets  up  fresh  repara- 
tive action  after  the  separation  of  the  superficial  slough,  and  this  process 
is  assisted  by  the  subsequent  local  emj)loyment  of  mild  astringent  solu- 
tions. The  condition  thus  described  is  most  commonly  met  with  in  lacer- 
ated cervices  with  everted  lips,  and  the  treatment  is  then  less  curative 
than  preparatory  to  the  plastic  operation.  These  strong  caustics  should  not, 
as  a  rule,  he  applied  oftener  than  once,  rarely  twice,  a  iveek.  In  the  interval, 
local  astringents  (to  be  described  hereafter)  may  be  used  through  the 
sjDeculum,  and  mildly  astringent  injections  should  always  be  advised. 
]\Iilder  solutions  of  these  caustic  fluids  are  not  generally  used,  except  of 
the  carbolic  acid,  which  is  so  popularly  employed  in  very  dilute  condition 
as  a  vaginal  injection.  The  acetic  and  pyi'ohgneous  acids,  and  the  iodized 
phenol  owe  their  chief  utility  to  their  powerful  caustic  effect,  and  this  is 
manifest  only  when  the  agent  is  apj)lied  pure  or  in  a  highly  concentrated 
state.  Strongly  diluted,  the  effect  would  be  no  better  and  no  worse  than 
ordinary  carbolic  or  vinegar  injections.  Each  of  these  agents  has  its  ad- 
vocates, who  prefer  it  to  all  others.  I,  for  my  part,  have  found  the  iodized 
phenol  to  act  more  efficiently  and  kindly  than  the  others,  and  therefore 
use  it  almost  exclusively  as  a  caustic  to  an  eroded  cervix  where  the  nitrate 
of  silver  solution  is  counteiindicated  or  fails. 

I  have  thus  far  omitted  to  include  the  nitrate  of  silver  in  the  discus- 
sion of  strong  caustics,  because  I  wish  to  devote  a  separate  paragraph  to 
this,  in  my  opinion,  most  valuable  of  all  tme  caustics,  astringents,  and  anti- 
phlogistics.  While  the  caustics  ah-eady  mentioned  are  beneficial  only 
when  apphed  pure,  and  are,  as  a  rule,  available  only  when  a  limited  space 
is  to  be  cauterized,  the  nitrate  of  silver  exerts  its  most  beneficial  effect  in 
gynecological  practice  chiefly  when  used  in  comparatively  mild  solutions, 
and  applied  to  the  whole  cervix,  vagina,  or  vulva.  I  have  ah-eady  ex- 
pressed my  opinion  of  the  solid  stick  as  an  application  to  the  cervix.  A 
saturated  solution  would  not  be  much  better.  But  solutions  ranging  from 
one  di-achm  to  ten  grains  to  the  ounce  have  a  utility  and  an  influence  pe- 
cuharly  their  own,  which  is  possessed  and  exerted  to  a  like  degTee  by  no 
other  caustic  or  astringent. 

In  acute  or  subacute  vaginitis,  chiefly  if  of  venereal  origin  or  in  inten- 
sity resembling  that  disease,  with  highly  congested  mucous  membrane  of 


APPLICATIONS    THROUGH   THE    SPECULUM.  175 

vagina  and  vulva  and  a  greenish  yellow,  jDungent  discbarge,  I  know  of  no 
application  which  will  so  soon  allay  the  hyperemia  and  control  the  secre- 
tion as  a  solution  of  the  nitrate  of  silver  of  the  strength  of  thirty  gTains  to 
the  ounce.  The  erosion  of  the  cervix,  so  commonly  met  with  in  these 
cases  if  they  have  existed  longer  than  a  few  days,  is  treated  and  cru-ed  by 
a  solution  of  forty  to  sixty  grains  to  the  ounce. 

Be  it  well  understood  that  not  every  such  acute  or  subacute  vulvo- 
vaginitis with  highly  congested  mucous  membrane  and  purulent  discharge, 
is  due  to  venereal  infection.  I  have  seen  severe  instances  of  the  kind  in 
virgins,  who  besides  w^ere  entirely  above  Suspicion.  An  exposure  to  cold 
duiing  menstruation,  an  overexertion,  may  bring  on  an  acrid  uterine  dis- 
charge, which  erodes  the  lips  of  the  os  exactly  as  the  upper  Hp  is  eroded 
by  a  discharge  from  the  nostrils  during  a  violent  coryza,  and  this  discharge, 
as  it  flows  toward  the  vulva,  infects  in  turn  each  portion  of  the  vaginal 
tract,  and  finally  the  vulvar  surface.  A  positive  diagnosis  of  gonorrheal 
vaginitis  must  usually  be  made  more  on  the  strength  of  the  antecedents 
and  character  of  the  patient,  and  on  the  admitted  or  suspected  jDossibility 
of  such  an  occiu'rence,  than  on  the  physical  aj)pearances.  Thus,  recently 
a  woman  presented  herself  to  me  for  a  profuse  leucorrhea,  which  she  said 
had  existed  for  about  three  weeks.  I  found  an  acute  vaginitis  of  the  most 
virulent  type,  with  a  j^rofuse,  offensive  greenish  discharge,  which  in  its 
intensity  so  much  resembled  gonorrhea  that  I  could  not  repress  my  con- 
viction that  it  really  was  such.  The  patient  was  a  respectable  mariied 
woman,  and  disclaimed  with  perfect  ingenuousness  any  knowledge  of  the 
cause  of  this  discharge.  Incidentally  she  mentioned  that  her  husband  had 
been  away  six  months  and  had  only  returned  three  weeks  ago,  shortly 
before  the  discharge  appeared.  The  coincidence  between  his  return  and 
the  vaginal  discharge,  I  am  convinced,  was  not  accidental,  and  the  etiology 
of  the  unquestionable  gonorrhea  was  revealed. 

After  this  digression,  which  seems  to  me  not  out  of  place  in  a  discus- 
sion on  the  treatment  of  vulvo-vaginitis,  I  will  describe  the  manner  in 
which  I  am  in  the  habit  of  applying  the  solutions  of  nitrate  of  silver  of 
various  strengths  to  the  cervix  and  vagina.  If  the  speculum  (either  va- 
riety) reveals  an  erosion  of  the  cervix,  I  touch  the  abraded  spot  gently  but 
thoroughly  with  a  cotton-wrapped  stick  dipped  in  a  silver  solution  of  3  j. 
to  3  j.  If  there  is  no  vaginitis  present,  I  simply  dry  the  cervix  with 
cotton  held  in  the  dressing  forceps,  and  push  a  tampon  covered  with  vase- 
line up  to  the  cervix  and  withdraw  the  speculum.  The  whitening  of  the 
cauterized  surface  through  the  formation  of  an  albuminate  of  silver  is  a 
proof  of  the  disintegration  or  desquaination  of  the  epithelium.  A  per- 
fectly healthy  mucous  surface  with  a  sound  epithelial  covering  remains 
unchanged  by  the  application  of  a  mild  solution  of  nitrate  of  silver.  This 
white  color  thus  shows  the  extent  and  degree  of  the  inflammation.  If, 
however,  the  vagina  is  congested  and  inflamed,  especially  if  the  eijithelium 
appears  swollen  or  abraded,  I  follow  the  application  to  the  cervix  by  pour- 
ing about  a  teaspoonful  of  silver  solution  of  3  ss.  to  3  j.  into  the  sj^ecu- 
lum,  and  then  gently  withdrawing  the  tube,  I  swab  the  vaginal  walls,  as 


176  MINOE    GYNECOLOGICAL    MANIPULATIONS. 

they  successively  become  exposed,  with  the  solution,  until  the  speculum 
is  almost  out  of  the  vagina.  By  then  depressing  its  funnel-shaped  mouth 
the  fluid  is  made  to  flow  out  into  a  cup,  and  any  excess  of  the  caustic  thus 
removed.  The  speculum  is  then  reintroduced  almost  lo  the  cervix,  and  a 
conical  tampon  thoroughly  covered  with  vaseline  inserted,  and  the  specu- 
lum removed.  It  is  always  well  to  protect  the  clothing  of  the  patient 
from  stains  of  the  silver  by  packing  cotton-wool  between  the  nates  and 
against  the  perineum,  which  will  absorb  the  almost  unavoidable  oozing  of 
a  few  drops  from  the  vagina  when  the  speculum  is  withdrawn. 

If  the  vulva  and  vaginal  orifice  are  also  inflamed  and  abraded,  as  is 
usually  the  case  when  the  discharge  is  acrid,  these  parts  are  gently  painted 
with  a  silver  solution  of  gr.  x.  to  3  j.,  and  a  strip  of  cotton-batting  smeared 
with  vaseline  is  placed  between  the  nymphse  and  pressed  into  the  vaginal 
orifice.  This  last  strip  is  removed  by  the  patient  at  the  next  micturition, 
the  vaginal  tampon  not  until  twelve  to  eighteen  hours  later  ;  mild  astrin- 
gent vaginal  injections  are  then  made  two  or  three  or  more  times  daily, 
unul  the  repetition  o:£  the  silver  process  in  three  to  six  days.  In  aggra- 
vated cases  the  silver  is  applied  every  other  day,  each  alternate  application 
being  of  a  milder  solution,  say  gr.  xv.  to  gr.  xx.  instead  of  3  ss.  to  the 
ounce.  If  a  few  weeks  of  this  treatment  do  not  show  marked  improvement, 
it  is  necessary  to  try  some  other  agent  to  the  cervix,  and  the  best  is  then 
undoubtedly  the  fuming  nitric  acid  superficially  applied  by  a  wooden  stick. 
The  iodized  phenol  and  the  saturated  solution  of  chromic  acid  may  have  a 
trial  also,  if  the  nitric  acid  fails  ;  and  it  certainly  must  be  an  obstinate  erosion 
which  resists  all  these  remedies  perseveringly  applied.  When  the  erosion 
is  that  of  an  everted  cervical  mucous  membrane,  however,  nothing  but  the 
repair  of  the  laceration  by  operation  will  fully  cure  the  case.  It  is  rare  that 
a  vaginitis  does  not  yield  to  the  silver  solution,  if  it  is  applied  with  sufficient 
frequency  and  perseverance  ;  the  relaxed  condition  of  the  vaginal  mucous 
membrane  usually  following  the  acute  stage  requires  other  remedies,  how- 
ever, and  here  the  astringents  to  be  mentioned  in  the  next  section  come 
into  play.  Should  the  silver,  conti-ary  to  expectation,  fail,  the  alum  or  zinc 
or  co]Dper  solutions  (  3  ss.  to  3  j-  to  |  j.),  or  tannin  in  powder  or  in  satu- 
rated solution  in  water  or  glycerine,  or  dilute  solution  of  tincture  of  chlo- 
ride of  iron  (  3  ]"■  to  3  iv.),  or  the  pure  fluid  extract  of  hydrastis  Canadensis 
or  eucalyptus  globulus,  painted  aU  over  the  cervix  and  vagina,  may  effect  a 
cure.  The  greased  tampon  and  cotton  strip  described  above  are  used  for 
the  purpose  of  preventing  friction  of  the  freshly  cauterized  surfaces  and 
probable  abrasion  of  the  epithelium  ;  this  precaution  should  never  be 
neglected. 

In  very  virulent  vaginitis,  especially  if  of  specific  origin  or  characterized 
by  distinct  enlargement  of  the  papillse  (so-called  "  granular  "  vaginitis),  it 
is  often  difficult  to  cure  the  disease  because  certain  portions  of  the  vaginal 
tract  are  not  reached  by  the  caustic  ;  small  crevices  between  the  rugse 
escape  uncauterized  and  form  the  foci  for  a  renewal  of  the  infection.  This 
is  due  to  a  want  of  sufficient  dilatation  of  the  canal  to  eftace  these  inequal- 
ities, and  may  be  overcome  to  a  certain  extent  by  using  a  large  speculum. 


APPLICATIONS    THROUGH    THE    SPECULUM.  177 

But  this  is  often  not  practicable  if  the  vaginal  orifice  is  small,  and  if  the 
canal  is  very  large  and  rugous  even  the  largest  speculum  in  use  will  not 
distend  its  walls  to  their  utmost.  To  obtain  this  desired  distention  and 
inspection  of  the  vaginal  canal  a  very  excellent  plan  has  been  suggested 
by  Dr.  Palmer,  of  Louisville.  He  places  the  woman  in  the  knee-breast, 
position,  elevates  the  perineum  with  the  Sims,  and  then  finds  the  vagina 
expanded  like  a  balloon,  with  every  wrinkle  and  fold  efiticed.  By  now 
swabbing  its  walls  with  the  caustic  he  is  absolutely  certain  that  no  spot, 
be  it  ever  so  minute,  escapes.  The  excess  can  be  mopped  out  or  drawn 
up  by  a  syringe,  and  the  tampon  is  then  introduced  with  the  forceps,  and 
the  Sims  removed.  I  have  found  this  method  excellent  in  cases  where  the 
ordinary  plan  through  the  tubular  speculum  had  failed.  It  can  also  be 
employed  with  any  of  the  fluid  astringents,  which  may  be  poured  into  the 
expanded  vagina  until  it  is  filled  to  the  brim  and  retained  there  so  long  as 
the  patient  can  endure  the  uncomfortable  position.  A  very  powerful  astrin- 
gent effect  can  evidently  be  exerted  on  the  vaginal  walls  in  this  manner, 
which  may  prove  beneficial  in  relaxation  and  more  or  less  complete  pro- 
lapse (rectocele,  cystocele)  of  that  organ. 

Astringents  and  Sti/ptics. — I  have  already  stated  that  certain  of  the 
stronger  agents  of  this  class  are  merely  painted  on  the  diseased  part 
through  a  speculum ;  the  excess  is  then  removed  and  an  astringent  or 
emollient  tampon  introduced.  If  a  styptic  or  particularly  strong  astringent 
effect  is  desired,  the  part  of  the  tampon  to  be  placed  in  apposition  to  the 
diseased  surface  is  soaked  in  the  agent.  These  applications  may  be  made 
through  either  form  of  speculum  which  best  exposes  the  part  to  be  treated. 
The  tincture  of  the  perchloride  and  the  solution  of  the  persulj^hate  of  iron 
may  be  applied  pure  or  mixed  with  a  proportion  of  glycerine  varying  with 
the  intensity  of  the  effect  desired.  A  mixture  of  bismuth  and  glycerine 
(it  should  be  made  of  the  thickness  of  cream)  is  applied  to  the  cervix  on 
absorbent  cotton,  and  is  particularly  recommended  for  "ulceration"  (I  sup- 
pose erosion  is  meant)  by  Dr.  Suesseroth,  of  Chambersburg,  Pa.  A  satu- 
rated solution  of  resin  in  alcohol  (known  as  James'  styptic)  is  used  chiefly 
in  cases  of  hemorrhage  from  carcinoma  of  the  cervix.  It  is  applied  on 
cotton  firmly  pressed  against  the  bleeding  surface  until  the  alcohol  evapo- 
rates and  leaves  the  tenacious  resinous  coating  as  a  hemostatic,  and  this 
cotton  is  then  retained  by  a  dry  tampon. ^ — It  may  not  need  renewal  at  all, 
or  a  recurrence  of  the  hemorrhage  may  call  for  a  fresh  application  at  any 
time.  The  dry  tampons  should  in  every  case  be  removed  in  twenty-four 
hours,  the  styptic  cotton  not  until  it  has  of  itself  become  detached. 

Dry  styptic  cotton  can  be  easily  prepared  and  kept  on  hand,  by  satu- 
rating the  cotton  with  a  solution  of  the  perchloride  or  persulphate  of  iron 
(the  strength  of  the  solution  varying  with  the  effect  desired  ;  stj-ptic,  equal 
parts,  or  stronger  ;  astringent,  one  tablespoonful  to  one-half  i:>int  or  pint 
of  water),  expressing  the  excess,  and  drying  it.  This  cotton  can  be  ap- 
plied either  in  small  pledgets  directly  to  the  affected  part,  or  in  large  tam- 
pons filling  the  whole  vagina.  Other  astringents  and  styptics,  such  as 
tincture  of  iodine,  alum,  zinc,  copper,  tannin,  can  be  prepared  in  the  same 
12 


178  MINOE    GYNECOLOGICAL    MAlSTIPULATIOlvrs. 

manner,  and  kept  on  liand  for  use  ;  the  solutions  sliould  be  alcoholic  or 
aqueous,  for  glycerine  does  not  evaporate. 

Aside  from  the  stj'ptic  effect  which  these  agents  all  possess  in  a  greater 
or  lesser  degree  in  accordance  with  the  strength  of  the  application,  their 
chief  utility  in  gynecological  j^i'actice  is  as  astringents.  And  the  one 
great  indication  for  the  use  of  local  astringent  applications  is  a  hypersecre- 
tion from  the  mucous  membrane  of  the  genital  tract.  This  hypersecretion 
may  be  due  to  an  acute  hyperemia  or  inflammation,  as  in  acute  vaginitis  or 
endometritis,  or  depend  on  a  chronic  relaxed  and  dilated  condition  of  the 
blood-vessels  and  glands.  In  either  case  the  choice  of  astringents  will 
differ,  the  acute  stage  requiring  first  the  apphcation  of  caustics,  as  already 
described  in  the  previous  section,  and  the  chronic  condition  calling  for  the 
persistent  use  of  the  vaiious  astringents  enumerated  in  the  list.  These  two 
stages  may  merge  one  into  the  other,  the  acute  into  the  chronic  or  (more 
rarely)  the  reverse  by  renewed  initation,  or  the  chronic  leucorrhea  may 
depend  u^Don  general  debihty  and  loss  of  tone.  In  the  latter  case  the  ad- 
ministration of  general  tonics  will  be  required  in  addition  to  local  astrin- 
gents ;  either  alone  will  prove  insufficient. 

The  solution  of  tannic  acid  in  glycerine  or  water  is  one  of  the  most 
efficient  astringents  in  use  in  gynecological  practice.  As  a  hemostatic  the 
dry  powder  alone  is  preferable.  When  the  astringent  effect  chiefly  is  de- 
sired, a  solution  of  tannin  in  water  (1  :  4  or  6)  will  act  better  than  if  gly- 
cerine be  used  as  a  vehicle  ;  but,  if  the  condition  be  an  acute  or  subacute 
one  and  an  antiphlogistic  and  emollient  effect  be  intended,  the  solution  in 
glycerine  (equal  proportions)  should  be  used.  If  burning  or  pain  be  pres- 
ent, the  addition  of  iodoform  to  the  tannin  and  glycerine  solution  (iodo- 
form 3  ij.  to  3  iv.  to  tannin  |  j.)  will  prove  useful,  the  tannin  masking  to 
some  extent  the  disagreeable  odor  of  the  iodoform.  Or  laudanum  or  tinc- 
ture of  hyoscyamus  may  be  added  to  the  application  in  pi'oportions  of  3  j. 
to   §  j.  of  mixture. 

The  best  way  of  applying  any  of  these  astringents  to  the  whole  vaginal 
tract  is  to  pour  a  teaspoonful  or  more  of  the  mixture  or  fluid  into  the 
tubular  speculum,  and  then  bring  each  part  of  the  vaginal  wall  in  contact 
with  the  astringent  by  slowly  mthdrawing  the  speculum  and  swabbing  the 
parts  successively  with  a  brush  on  a  long  handle  or  a  cotton-wrapped  stick. 
The  excess  may  then  be  allowed  to  run  out  into  a  cujd,  or,  if  it  be  slight, 
is  left  in  the  vagina,  and  a  conical  tampon  soaked  either  in  pure  glycerine 
or  in  the  same  solution  is  introduced,  held  fast  by  the  dressing-forceiis, 
and  the  speculum  removed. 

Thus  the  mixture  of  the  tincture  of  the  perchloiide  of  iron  and  liquor 
ferri  persulphatis  with  glycerine  (one  drachm  to  one  ounce,  or  weaker), 
the  giycerole  of  tannin,  alum,  or  bismuth  (used  on  account  of  the  supposed 
si^ecific  effect  of  bismuth  on  the  hypersecretion  of  mucus),  the  decoctions 
of  oak-  and  willow-bark,  the  fluid  extracts  of  hydrastis  and  pinus  Cana- 
densis and  of  eucalyptus,  are  applied  to  the  vaginal  mucous  membrane.  If 
the  solution  be  a  very  strong  one,  it  is  generally  best  not  to  leave  it  in 
contact  so  long  as  would  be  the  case  if  a  tampon  soaked  in  the  same  were 


APPLICATIONS    THROUGH    THE    SPECULOf.  179 

introcTuced,  but  to  apply  instead  a  tampon  soaked  in  a  milder  solution  or 
in  glycerine,  or  covered  with  vaseline.  It  is  important  that  the  cord  at- 
tached to  the  tampon  should  be  a  stout  one,  since  it  might  break  in  the 
attempt  to  remove  the  cotton  from  the  contracted  vagina  and  produce  in- 
conveniences to  be  described  hereafter.  If  it  be  unnecessary  to  apply  the 
astringent  so  thoroughly,  or  if  a  cylindrical  speculum  be  not  at  hand,  the 
astringent  solution  can  be  applied  by  soaking  a  tampon  in  it  and  intro- 
ducing it  through  either  of  the  three  varieties  of  specula,  lea\ing  it  in  situ 
for  at  least  twenty-four  hours.  Care  should  be  taken  that  the  excess  of 
fluid  be  thoroughly  expressed  from  the  tampons  before  they  are  crowded 
into  the  speculum,  in  oi'der  to  prevent  the  escape  of  the  astringent  from 
the  mouth  of  the  speculum  and  the  soiling  of  the  linen  by  such  of  them  as 
stain  (ii'on,  tannin,  oak-bark  decoction,  etc.). 

These  astringent  apphcations  should  be  repeated  three  times  a  week  ; 
in  very  obstinate  cases,  or  where  remedies  of  only  moderate  strength  can 
be  employed,  every  day,  until  improvement  is  manifested.  The  addition 
of  a  nai'cotic  (tr.  opii,  hyoscyami,  or  conii)  to  the  astringent  solution  in 
which  the  tampon  is  soaked  is  always  indicated  when  pain  exists,  or  the 
aj)plication  is  likely  to  be  followed  by  pain.  The  quantity  of  the  narcotic 
need  not  be  estimated  to  a  nicety,  as  comparatively  little  is  absorbed  from 
the  vagina  ;  a  teaspoonfvil  of  either  of  the  three  agents  mentioned  will 
ordinarily  suffice  for  a  tampon. 

The  fluid  extracts  of  pinus  Canadensis  and  eucalyptus  globulus  may  be 
used  either  pure  or  mixed  with  equal  parts  of  glycerine.  They  are  bene- 
ficial chiefly  in  cases  of  acute  and  subacute  congestion  of  the  ceiwix  and 
vagina,  as  in  paj^illary  erosions,  endotrachelitis  and  cystic  hyperplasia  of  a 
lacerated  and  everted  cervix.  The  pure  extract  should  be  painted  over  the 
cervix  and  a  tampon  soaked  in  the  glyoerine  solution  then  apphed.  On 
the  recommendation  of  Dr.  Andrew  F.  Currier,  late  house-surgeon  at  the 
Woman's  Hospital,  I  have  recently  been  using  a  solution  of  equal  parts  of 
eucalyptus  and  glycerine  on  tampons  as  an  anesthetic  in  chronic  j)elvic 
cellulitis  and  ovaritis,  but  so  far  I  cannot  say  that  I  have  witnessed  the  de- 
cided beneficial  effects  reported  by  Dr.  Currier. 

Pure  vinegar  has  chiefly  a  stj'ptic  and  disinfectant  property  ;  it  can  be 
used  in  default  of  something  better  for  either  of  these  objects  ;  either 
through  a  speculum  or  on  tamjions. 

It  is  a  good  rule,  after  using  any  local  remedy  for  a  reasonable  length 
of  time  without  appreciable  benefit,  either  to  interrupt  it  for  a  short  time 
to  give  the  vis  medicatrix  naturce  an  opportunity  to  assert  itself,  or  to 
change  the  remedy. 

An  obstinate  leucon'hea  may  require  the  whole  list  before  the  jDroper 
agent  is  found.  An  old  chronic  leucorrhea  of  this  character  can,  in  my 
opinion,  be  cured  only  by  the  persevering  and  frequent  local  use  of  as- 
tringents, through  a  speculum,  together  with  the  hot  vaginal  douche,  as 
already  described.  Simple  astringent  injections  are  utterly  valueless  in  a 
curative  sense  ;  they  merely  keep  the  affectiou  at  a  standstill,  and  inaui-e 
cleanliness. 


180  MINOR    GYNECOLOGICAL    MANIPULATIONS. 

It  is  almost  needless  to  say  that  if  an  endometritis  exists,  it  must  be 
treated  in  conjunction  with  the  vaginal  leucorrhea  and,  if  possible,  cured, 
before  a  permanent  improvement  can  be  expected  in  the  lattei*. 

Alteratives. — Iodine  and  its  compounds  are  the  only  real  alterative  and 
absorbent  agents  which  are  directly  applied  to  the  cervix,  always  except- 
ing the  hot  vaginal  douche.  The  effect  derived  from  these  apphcations 
is  on  the  one  hand  that  of  counter-irritation  to  the  inflamed  and  congested 
cervix  and  vaginal  mucous  membrane,  and  of  contraction  of  the  capillaries ; 
and  on  the  other,  that  of  stimulation  of  the  lymphatics  to  absorb  the  hy- 
perplastic tissue  in  areolar  hyperplasia  and  the  exudation  of  plastic  lymph 
in  pelvic  peritonitis  and  cellulitis.  It  is,  therefore,  in  areolar  hyperplasia 
(or  chronic  subinvolution,  for  I  believe  deficient  puerperal  involution  to  be, 
at  least,  a  frequent  starting-point  of  true  "  areolar  hyperplasia  ")  of  the 
whole  uterus,  or  cervix  alone,  in  subacute  pelvic  peritonitis  and  cellulitis, 
and  in  the  so-called  "  chronic"  forms  of  these  latter  affections  of  the  pelvic 
peritoneum  and  cfeUular  tissue,  that  we  should  use  these  local  counter-irri- 
tants and  alteratives,  and  may  frequently  expect  material  benefit  from 
them.  By  the  persistent  application  to  the  vaginal  roof  and  cervix,  once  or 
twice  a  week  for  several  months,  of  these  agents,  chiefly  the  pure  tincture 
of  iodine,  I  have  seen  most  decided  diminution  in  size  of  a  hyiDcrplastic 
uterus  with  marked  ameUoration  of  the  various  distressing  hystero-neuroses 
so  characteristic  of  this  affection,  and  gradual  softening  and  absorption  of 
the  exudation  in  not  too  old  cases  of  j)elvic  peritonitis  and  cellulitis.  I 
cannot  say  as  much  for  the  dispersion  of  old  adhesions  and  callosities  of 
the  jDarametran  tissue,  which  by  their  pressure  on  nerve -filaments  and  dis- 
tortion of  uterus  and  ovaries  produce  many  of  the  annoying  aches  and 
pains  complained  of  by  the  victims  of  "chronic  pelvic  peritonitis  and  cel- 
lulitis ;  "  these  really  cicatricial  tissues  remain  unaffected  by  all  alteratives, 
and  the  most  one  can  hope  to  do  with  these  apj)lications  is  to  relieve  any 
accidentally  accompanying  edema  or  intercurrent  exacerbation  of  the  old 
affection.  This  can  usually  be  done,  and  I  have  therefore  always  felt 
mj'self  justified  in  extending  to  the  patients  a  prospect  of  relief,  although 
small  hope  of  a  perfect  cure.  I  have  in  course  of  time  come  to  look  upon 
the  periodical  and  systematic  use  of  alteratives  to  the  cervix  and  vaginal 
cul-de-sac  in  these  affections  as  so  beneficial,  in  conjunction  with  glycerine 
and  hot  injections,  that  I  rarely  treat  a  case  of  areolar  hyperplasia  or  sub- 
acute or  "  chronic  "  pelvic  peritonitis  or  cellulitis  otherwise  than  by  the 
application  with  a  swab  once  or  twice  a  week  through  the  speculum  of 
jDiu-e  tincture  of  iodine  to  the  cervix  and  vaginal  vault,  followed  by  a  gly- 
cerine tampon,  and  always  accompanied  by  the  hot  vaginal  douche.  If  the 
iodine  is  used  but  once  a  week,  on  one  or  both  of  the  remaining  alternate 
days,  I  introduce  a"  tampon  soaked  in  a  mixture  of  tincture  of  iodine  and 
glycerine  (1  :  4),  or  iodoform  and  glycerine  (1  :  8  with  one  drop  of  oil  of 
peppermint  or  balsam  of  Peru  added  for  each  fluid  drachm,  to  correct  the 
odor),  or  of  iodoform  and  chloral  in  glycerine  (iodoform  3  j-,  chloral  gr. 
XX.,  glycerine  3  j.),  and  leave  it  i7i  situ  for  twenty-four  hours.  The  addi- 
tion of  the  chloral,  besides  most  efficiently  deodorizing  the  iodoform,  is 


APPLICATIONS    THROUGH    THE    SPECULUM.  181 

especially  beneficial  as  a  local  anesthetic  for  the  pehic  neuralgise  so  gen- 
erally complained  of  in  chronic  pelvic  cellulitis  and  peritonitis  ;  it  acts  also 
as  a  mild  caustic  on  cervical  erosions.  Of  late,  I  have  found  better  effects 
from  a  mixture  of  tincture  of  iodine  and  tincture  of  aconite  root,  equal 
parts,  both  to  the  vaginal  vault  and  abdominal  wall.  And  the  frequent, 
even  daily  passage  of  a  mild  constant  current  of  electricity  through  the 
pelvic  organs  (one  pole  in  the  vagina,  the  other  by  a  large,  flat,  wet  sponge 
on  the  abdomen)  has  a  marked  effect  in  allaying  pain,  and  eventually  dis- 
persing exudations.  By  the  persistent  use  of  these  remedies  (by  persistent 
I  mean  for  from  three  to  six  months,  and  we  should  expressly  caution  the 
patients  not  to  expect  even  the  sign  of  an  improvement  sooner)  we  may 
confidently  hope  to  relieve  our  patients  at  least,  if  we  cannot  actually  cure 
them.  As  any  relief  is  grateful  in  these  distressing  afiections,  of  which 
the  h^Tperplasia  particularly  exerts  a  most  deleterious  effect  on  the  nervous 
system,  even  this  prospect  cheers  the  patient  and  is  worthy  of  realization. 
The  patient  should,  howevex',  be  warned  that  a  cessation  of  the  treatment 
after  a  merely  temporary  improvement  will  invariably  entail  a  return  of 
the  symptoms  and  a  recommencement  of  the  treatment  at  the  status  quo 
ante. 

A  fresh  cellulitis  of  only  a  few  days'  or  a  week's  duration  should  not  be 
treated  by  the  local  api^lication  of  alterative  drugs.  So  long  as  the  exuda- 
tion is  markedly  tender  to  the  touch  and  the  vaginal  temperature  elevated, 
hot  injections  and  abdominal  poultices,  perhaps  preceded  by  a  blister,  are 
the  proper  treatment.  Only  when  all  acute  symptoms  have  subsided  may 
the  dispersion  and  absorption  of  the  exudation  be  aided  by  remedies  de- 
scribed in  tliis  section. 

I  have  thus  far  spoken  only  of  the  tissues  to  which  the  alterative  is 
directly  applied.  But  of  scarcely  less  value  is  their  use  in  that  still  more 
harassing  and  even  less  curable  affection,  subacute  and  chronic  oophoritis. 
The  chronically  congested  and  hyperesthetic  ovary  becomes  in  time  hyper- 
plastic, its  stroma  sclerifies  (interstitial  oophoritis)  and  the  constant  wear- 
ing, dragging  pain  in  the  groin  and  back  makes  life  a  burden  to  the 
sufferer.  Often  the  ovary  is  embedded  in  more  or  less  fresh  plastic  ex- 
udation, the  pressure  of  which  causes  flashes  of  pain  to  radiate  all  through 
the  body.  Now,  while  but  little  more  than  slight  temporary  relief  can  be 
afforded  by  the  local  apphcation  of  alteratives  and  counter-irritants  to 
the  region  of  the  ovary,  abdominal  or  vaginal,  when  that  organ  has  un- 
dergone sclerotic  degeneration,  there  is  no  doubt  whatever  that  much 
good  may  be  done  to  the  congested,  subacutely  inflamed  organ,  whether 
it  be  enclosed  in  plastic  lymph  or  not,  by  the  frequent  systematic  ap- 
plications above  mentioned.  The  employment  of  counter-in-itation  by 
blisters  and  iodine  to  the  abdominal  ovarian  region  is  at  the  same  time 
decidedly  advisable.  If  an  ovary  is  prolapsed,  and  therefore  in  close  con- 
tiguity to  the  vaginal  pouch,  the  application  will  be  still  more  effective.  I 
can  honestly  say  that,  both  in  hospital  and  private  practice,  I  have  many 
times  relieved  patients  of  their  ovaralgia  dependent  on  congestion  and 
subacute    inflammation  of   the  organ,  by  the  frequent,  persistent  use  of 


182  MINOR    GYNECOLOGICAL    MANIPULATIONS. 

the  above  remedies,  and  I  have  relieved  some  of  them  not  only  tempo- 
rarily, but  if  they  were  as  persevering  as  they  were  directed  to  be,  per- 
manently. I  claim  to  cure  these  cases  quite  as  little  as  I  do  a  hyperj)lasia 
or  cicatricial  cellulitis,  but  I  know  that  they  can  be  immensely  and  often 
permanently  relieved  in  the  manner  indicated  if  their  perseverance  will 
only  keep  pace  with  that  of  their  physician.  Unfortunately  such  cases 
soon  tire  of  the  routine,  although  the  treatment  is  neither  very  painful  nor 
distressing,  and  skip  a  few  months  after  the  first  improvement,  only  to  re- 
turn again  and  again.  Those  who  have  persevered  have  never  had  occa- 
sion to  regret  it. 

I  have  spoken  of  the  local  influence  of  alteratives  only  in  describing  the 
effects  to  be  obtained  by  their  use.  In  the  main,  this  may  be  considered 
the  chief  benefit,  especially  as  regards  the  tincture  of  iodine ;  but  there  can 
be  no  doubt  that  it,  and  particularly  the  iodoform  and  iodide  of  potash  are, 
to  a  certain  extent,  absorbed  and  act  through  the  vascular  system.  But  the 
power  of  absorption  of  the  vaginal  mucous  membrane  is  vastly  inferior  to 
that  of  the  endometrium  or  rectal  mucosa. 

The  tincture  of  iodine  may  be  applied  in  two  ways  :  mixed  with  glycer- 
ine on  a  cotton  tampon  and  left  in  the  vagina  for  twenty-four  hours,  or 
pure  against  the  cervix  and  vaginal  pouch  by  a  cotton-wrapped  stick.  The 
first  method  requires  no  other  explanation  than  that  it  is  done  in  the  usual 
way,  and  that  a  second  dry  tampon  should  be  placed  over  the  first  to  pre- 
vent the  escape  of  the  fluid  on  the  delicate  vulva. 

The  application  of  the  tincture  of  iodine  on  a  cotton-wrapped  stick  may 
be  made  through  a  cylindrical,  a  bivalve,  or  a  Sims  speculum.  Through  a 
cylinder  one  cannot  be  quite  sure  that  the  iodine  reaches  the  exact  spot  in 
the  fornix  vaginae,  or  indeed  the  fornix  at  all ;  for  the  cervix  fills  uj)  the 
lumen  of  the  speculum  and  there  is  no  room  to  crowd  the  stick  with 
iodine  beyond  it ;  besides,  by  doing  so,  the  fluid  would  be  squeezed  out 
and  flow  down  the  speculum.  Or  the  vaginal  walls  prolapse  in  the  specu- 
lum and  intervene  between  the  applicator  and  the  fornix.  However,  for 
painting  the  cervix  alone,  the  cylindrical  speculum  answers  very  well. 
Through  the  bivalve  the  same  objections  hold  good,  j^erhaps  to  a  lesser  ex- 
tent. But  I,  habitually  using  as  I  do  the  Sims,  prefer  it  decidedly  for  this 
maneu\Te  also,  and  have  no  difficulty  in  executing  it,  even  without  a  nurse. 
An  accident  to  be  avoided  in  making  this  application  is  to  bi'ing  the  iodine 
in  contact  with  the  sensitive  vaginal  orifice  and  vulva,  which  may  readily 
occur  if  the  soaked  swab  is  carelessly  introduced  or  so  freely  saturated  as 
to  allow  the  excess  of  iodine  to  flow  along  the  crease  in  the  anterior  wall 
and  on  the  vestibule.  "While  the  iodine  jDroduces  scarcely  more  than  a 
slight  smarting  when  applied  to  the  mucous  membrane  of  the  vagina 
proper,  it  gives  intense  pain  when  it  touches  the  thinner  and  more  sensi- 
tive covering  of  the  vulva,  particularly  the  vestibule.  And  that  this  readily 
happens,  unless  proper  precautions  are  taken,  is  at  once  apparent  on  con- 
sidering the  peculiar  position  occupied  by  the  patient,  and  the  downward 
incline  of  the  vaginal  canal  from  within  outward.  After  introducing  the 
Sims,  and  before   making  the  application,  it  is  well,  therefore,  to   pack 


APPLICATIONS    THROUGH   THE    SPECULUM.  183 

some  absorbent  cotton  against  the  bulb  of  the  urethra  and  vestibule  as  a 
protection  to  these  parts,  and,  what  is  even  more  important,  the  peculiar 
upward  twist  described  on  page  85  should  be  given  to  the  speculum  so  as 
to  place  the  point  of  the  internal  blade  decidedly  lower  than  the  perineal 
angle  of  the  speculum.  In  this  manner  the  inclination  of  the  vaginal 
canal  is  reversed,  and  fluids  poured  into  it  will  flow  inward  and  downward 
toward  the  fornix  instead  of  outward  and  downward,  as  they  ordinarily 
would  in  Sims'  position.  The  cervix  being  thoroughly  exposed,  the  cotton- 
wrapped  end  of  the  stick  is  dipi^ed  in  the  tincture  of  iodine  (which,  like  all 
fluid  applications,  it  is  well  to  keep  in  a  wide-mouthed  bottle)  the  excess 
squeezed  out  by  gently  pressing  the  cotton  against  the  edge  of  the  bottle, 
and  carefully  passed  through  the  vaginal  orifice  up  to  the  fornix.  Whether 
it  is  the  object  to  paint  the  cervix  only  or  the  whole  fornix,  it  is  advisable 
to  be  on  the  safe  side  and  make  the  application  as  thorough  as  j)0ssible. 
I  therefore  generally  swab  the  whole  cervix  and  posterior  fox'nix  vaginee 
until  all  of  the  fluid  has  been  expressed  from  the  cotton,  thrusting  the 
stick  a  number  of  times  rapidly  and  gently  against  different  parts  of  the 
fornix.  To  make  the  application  thoroughly  can  do  no  harm,  and  it  is  evi- 
dent that  the  greater  the  surface  covered  by  the  iodine  in  a  case  of  old 
pelvic  cellulitis  the  more  efficient  will  the  application  be.  After  such  an 
application  the  vaginal  pouch  and  cervix  are  almost  black  in  color,  and  the 
external  os  is  difficult  to  distinguish.  It  is  therefore  advisable  to  make  any 
applications  to  the  endometrium,  which  may  also  be  required,  previous  to 
this  swabbing.  When  the  application  is  completed,  the  stick  is  removed 
with  equal  care,  in  order  not  to  touch  the  vulva,  and  any  positive  excess  of 
fluid  iodine  wdped  away  by  cotton  on  the  dressing-forceps,  which  it  is  weU. 
to  have  at  hand  in  case  the  fluid  should  accidentally  flow  toward  the 
vulva  in  spite  of  all  precautions.  A  tampon  thoroughly  soaked  in  glyce- 
rine and  expressed  is  then  introduced  to  the  fornix  by  the  dressing-forceps 
and  the  speculum  removed.  In  removing  the  Sims  after  a  tampon  has 
been  placed  it  may  be  as  well  to  mention  here  a  precaution,  which  will  be 
referred  to  again,  viz.,  to  keep  the  point  of  the  vaginal  blade  of  the  specu- 
lum backward,  and  the  whole  blade  in  close  contact  with  the  posterior  wall 
until  the  instrument  is  entirely  withdrawn.  If  the  point  of  the  vaginal 
blade  is  directed  forward  while  being  withdrawn,  the  tampon  will  be  lifted 
out  with  it. 

The  glycerine  tampon  is  removed  on  the  next  day  and  the  usual  hot 
vaginal  injection  made.  It  is  scarcely  necessary  to  tell  the  practitioner 
that  an  injection,  hot  or  otherwise,  is  not  to  be  used  when  a  tampon  is  in 
the  vagina  ;  but  it  is  by  no  means  unnecessary  to  tell  the  patient  so,  since 
very  few  will  consider  the  tampon  an  obstacle  to  the  usual  injection. 

These  iodine  applications  should  be  made  at  least  once,  in  obstinate  or 
aggravated  cases  twice,  a  week,  and  even  every  other  day  for  a  short 
period.  But  so  frequent  applications  are  very  liable,  in  conjunction  with 
the  softening  effect  and  pressure  of  the  tampon,  to  produce  excoriation  of 
the  vaginal  mucous  membrane,  which  is  usually  not  desirable,  although 
on  the  cervix  alone  it  may  do  good  in  areolar  hyperplasia.    For  this  reason, 


184        MINOE  GYNECOLOGICAL  MANIPULATION'S. 

I  rarely  employ  the  strong  Churchill's  tincture  of  iodine  for  vaginal  ap- 
plications, having  found  that  it  excoriates  too  rapidly,  and  thereby  obliges 
an  intermission  of  the  applications. 

I  have  been  thus  explicit  in  describing  the  details  of  this  maneuvi-e, 
because  I  have  witnessed  over  and  over  again  the  blunders  made  by  my 
students  in  the  very  points  cautioned  against  above  (and,  indeed,  have 
occasionally  myself,  when  in  haste,  had  the  iodine  flow  on  the  vulva  be- 
cause I  filled  the  swab  too  full  or  neglected  the  speculum  twist  or  vestib- 
ular cotton),  and  was  made  disagi-eeably  conscious  of  the  sharp  pain  un- 
necessarily inflicted  on  the  patients  by  the  iodine  touching  the  vulva.  It 
is  true,  the  pain  lasts  but  a  few  minutes,  and  may  be  allayed  by  placing 
glycerine-soaked  cotton  between  the  labia  ;  but,  we  are  so  often  obliged  to 
inflict  necessary  pain  on  our  patients  during  gynecological  manipulations, 
that  it  is  certainly  desirable  to  avoid  doing  so  unnecessarily  whenever 
possible. 

I  have  never  seen  any  positive  unpleasant  consequences  follow  this 
profuse  iodization  of  the  vagina  ;  still,  occasionally,  a  patient  comjDlains  at 
the  next  visit  of  having  felt  some  abdominal  pain  or  lost  some  blood  after 
the  last  application,  and  it  is  best  in  such  cases  to  make  the  application 
very  mildly  and  gently,  or  substitute  the  iodoform  tampon  presently  to  be 
described,  for  one  or  two  visits.  At  times  it  is  well,  as  with  eveiy  species 
of  continuous  local  treatment  in  gynecology,  to  omit  all  direct  applica- 
tions for  one  or  two  weeks  and  give  the  patient  locally  and  constitutionally 
a  rest.  Often  the  beneficial  influence  of  the  treatment  is  not  experienced 
until  that  treatment  with  its  necessary  excitement  has  been  discontinued. 

The  application  of  iodoform  to  the  cervix  and  vagina  in  the  shape  of 
powder  with  and  without  tannin  has  already  been  discussed  under  Solids  ; 
but  a  preferable  method  of  employing  it  when  an  alterative  and  discutient 
eflect  is  desired  is  through  a  speculum  in  the  form  of  a  solution  in  glyce- 
rine (1 :  8)  with  the  addition  of  one  drop  of  oil  of  peppermint,  five  drops 
of  balsam  of  Peru,  or  gr.  ij.  of  hydrate  of  chloral  to  the  drachm  of  fluid,  as 
a  deodorant.  I  have  already  spoken  of  the  relative  merits  of  these  three 
agents  as  deodorants  of  iodoform,  and  will  merely  repeat  that  the  chloral 
is  the  best.  This  solution,  after  being  well  shaken,  is  applied  to  the  cervix 
and  upper  portion  of  the  vagina  by  a  cotton  swab,  and  a  tampon  is  then 
soaked  in  the  liquid,  expressed,  and  introduced,  followed  by  a  dry  tampon 
to  prevent  the  escape  of  the  fluid  from  the  vagina.  This  application  may 
be  repeated  every  other  day,  or  even  every  day,  the  tampon  being  always 
retained  for  from  eighteen  to  twenty-four  hours.  In  the  interval  the  usual 
hot  injections.  The  iodoform  tampon  is  not  in  the  least  painful ;  on  the 
contrary,  it  has  a  soothing,  gently  narcotic  ■  effect,  and  is  therefore  indi- 
cated chiefly  where  dull  pelvic  pain  exists,  as  in  the  exudation  of  old  pelvic 
peritonitis  and  cellulitis,  and  chronic  ovaritis.  The  alterative  and  absorb- 
ent qualities  of  the  iodine  will  exert  their  influence  also  in  this  com- 
bination, and  may  even  be  of  some  benefit  in  areolar  hyperplasia.  The 
counter-irritant,  stimulant  effect  of  the  tincture  of  iodine  is  not  exerted 
by  the  iodoform.     The  solution  of  iodide  of  potash  is  applied  on  cotton 


APPLICATIONS    THROUGH   THE    SPECULUM.  185 

tampons  in  the  same  manner  as  the  iodoform.  The  solution  may  be  in 
glycerine  or  water,  or  both  together.  The  glycerine  is  preferable,  and 
the  strength  should  be  not  more  than  3  ss.  to  the  ounce.  A  stronger  solu- 
tion I  have  found  to  cause  smarting.  It  is  best  prevented  from  oozing  on 
the  vulva  by  a  dry  tamjDon.  The  cotton  should  be  retained  for  from 
eighteen  to  twenty-four  hours,  and  be  repeated  every  two  or  three  days. 
In  fact,  the  indications  and  treatment  are  precisely  the  same  as  when 
iodoform  is  used.  If  the  application  gives  pain,  a  drachm  of  tincture  of 
opium  may  be  added  to  each  tampon. 

The  same  rule  applies  to  these  two  remedies  as  has  already  been  stated 
for  the  tincture  of  iodine,  viz.,  perseverance.  AVith  it  much  may  be 
achieved  in  these  intractable  cases  ;  without  it,  little  or  nothing. 

The  canthai'idal  collodion  has  been  included  under  the  head  of  Al- 
teratives, because  that  is  really  the  effect  produced  by  blistering  the  cer- 
vix. It  should  be  applied  only  to  the  cervix,  never  to  the  vagina,  since 
adhesions  between  the  two  parts  might  otherwise  take  place.  The  indi- 
cation is  areolar  hyperplasia,  particularly  the  old,  sclerotic  variety,  which 
refuses  to  yield  to  milder  measures,  and  the  object  that  of  counter-irrita- 
tion, depletion,  and  stimulation  to  absorption  of  the  adventitious  tissue. 
The  collodion  is  applied  with  a  brush  through  a  cylindrical  sj)eculum  only, 
the  excess  wiped  up,  and  a  glycerine  tampon  introduced.  If  vesication 
has  not  taken  place  on  removal  of  the  tampon  after  twenty-four  hours,  the 
application  is  repeated,  and  so  on  until  a  decided  blister  is  raised ;  this  is 
pricked,  and  daily  glycerine  tampons  apphed  to  increase  the  watery  dis- 
charge from  the  uterine  capillaries.  When  the  blister  has  healed,  the 
aj)plication  may  be  repeated,  and  this  treatment  may  be  continued  through 
many  months.  At  the  jDresent  day,  blistering  the  cervix  for  hj'-perplasia  is 
not  fashionable,  having  been  supplanted  by  operative  measures,  such  as 
amputation  ;  but  doubtless  it  is  a  beneficial  remedy,  and  should  not  be 
neglected  when  the  iodine  and  other  applications  mentioned  have  failed. 

Hydragogue. — The  only  remedy  of  this  class  which  we  use  in  gyne- 
cology is  glycerine.  The  introduction  of  this  remedy  into  gynecological 
practice  for  the  express  purjDOse  of  producing  and  sustaining  a  free  wa- 
ievy  discharge  from  the  hyperemic  female  genital  organs,  dates,  so  far  as  I 
am  aware,  from  the  new  era  in  gynecology  inaugurated  by  J.  Marion  Sims. 
Since  his  time  glycerine  forms  the  inseparable  companion  of  the  gyne- 
cologist, and  undoubtedly  deserves  the  universal  esteem  in  which  it  is 
held.  Its  indications  ai-e  precisely  identical  with  those  which  call  for  a 
local  alterative — that  is,  all  acute,  subacute,  and  chronic  inflammatory  or 
hyperemic  conditions  of  the  pelvic  organs.  As  an  auxiliary  to  these  al- 
teratives it  is  a  specially  valuable  agent ;  and  its  use  in  conjunction  with 
the  systematic  hot  vaginal  douche  serves  to  mollify  whatever  local  irrita- 
tion the  douche  may  produce,  and  to  intensify  its  antiphlogistic  effects. 
Almost  every  application  to  the  cervix,  vagina,  or  endometrium  is  fol- 
lowed by  the  immediate  introduction  of  a  cotton  tampon  soaked  in  glyce- 
rine, which  is  retained  for  from  eighteen  to  twenty-four  hours  and  produces 
a  profuse  watery  discharge.     Of  the  prospective  occurrence  of  this  dis- 


18G  MINOE    GYNECOLOGICAL    MANIPULATIONS. 

charge  the  patients  should  be  warned,  partly  that  they  may  protect  their 
clothing,  and  partly  to  avoid  a  belief  on  their  part  that  the  leucorrhea 
from  which  they  were  probably  suffering  has  been  increased  by  the  treat- 
ment. The  latter  reason,  it  will  be  observed,  is  as  much  in  the  interest  of 
the  physician  as  of  the  patient. 

Glycerine  is  applied  to  the  vagina  and  cervix  chiefly  on  tampons  of 
cotton-wool,  which  have  been  soaked  in  the  liquid  and  squeezed  so  as  not 
to  drip.  The  best  mode  of  introducing  these  tampons  is  always  through 
a  speculum,  because  not  only  can  a  larger  tampon  be  used,  but  the  exact 
location  of  the  plug  regulated.  Both  these  points  are  of  importance, 
particularly  the  latter,  as  when  it  is  desired  to  exert  pressure  against  a 
particular  spot,  say  behind  the  uterus  in  retrodisplacement  of  that  organ 
or  an  enlarged  ovary.  The  use  of  glycerine,  to  be  really  productive  of 
benefit,  should  be  even  more  systematic,  frequent,  and  persistent  than 
that  of  the  alteratives  in  conjunction  with  which  it  is  generally  used. 
Glycerine  tampons  should,  therefore,  be  introduced  daily ;  if  two  hot  in- 
jections per  day  are  used,  even  twice  daily,  after  each  injection.  Mani- 
festly, but  few  patients  can  afford  to  see  a  physician  twice  a  day  for 
months  to  have  this  done,  and  perhaps  few  physicians  would  care  to  be 
saddled  with  such  routine  work.  A  nurse  may  easily  be  taught  this  sim- 
ple maneuvre,  and  I  have  frequently  succeeded  in  accomplishing  the  ob- 
ject in  this  way.  But  comparatively  few  patients  have  trained  niarses  at 
their  disposal;  and  it  has,  therefore,  been  sought  to  overcome  the  difficulty 
by  constructing  tubes  with  piston-rods,  into  which  the  tampon  is  put  and, 
the  tube  being  introduced  into  the  vagina  by  the  patient  herself,  the  tam- 
pon is  expressed  and  the  tube  removed.  The  objection  to  these  tubes  is,  1, 
that  theii'  calibre  is  necessarily  so  small  (the  patients  are  afraid  to,  or  act- 
ually cannot,  introduce  a  fair-sized  tube)  that  the  tampons  are  mere  apolo- 
gies, and  do  but  little  good  ;  and  2,  that  many  patients  are  absolutely  un- 
able to  introduce  them,  partly  through  timidity  or  awkwardness,  partly 
through  narrowness  and  tenderness  of  the  vaginal  orifice.  Such  tubes 
have  been  devised  by  Thomas,  Barnes,  and  others  (see  Fig.  94),  but  they 
have  never  become  really  popular,  either  with  physicians  or  patients.  I 
have  always  found  it  possible  to  instruct  patients  who  had  had  children, 
and  whose  vaginal  orifices,  therefore,  were  not  too  narrow,  to  introduce  an 
ordinary-sized  tampon  themselves  by  assuming  the  dorsal  position  with 
separated  thighs  and  pushing  the  tampon  upward  as  far  as  possible  with 
the  fingers.  But,  it  is  not  to  be  denied  that  such  tampons  rarely  reached 
or  remained  in  the  fornix  vaginae  where  they  were  wanted,  and  that  gener- 
ally a  T-bandage  was  required  to  prevent  their  slipping  out  of  the  vagina 
during  walking.  Only  through  a  sj)eculum  and  with  a  practised  hand  can 
a  tampon  be  placed  in  the  fornix  and  in  close  apposition  with  the  cervix 
as  it  should  be. 

I  shall  refer  to  the  subject  of  tampons  more  at  length  in  the  chapter 
on  that  subject.  Glycerine  injections  have  been  found  beneficial  in  va- 
ginitis and  ulcerated  conditions  of  the  vagina,  acting  simply  as  an  emol- 
lient with  the  very  slight  caustic  effect  pecuHar  to  glycerine  added.     The 


APPLICATIOISrS    THROUGH    THE    SPECULUM.  187 

vagina  may,  for  the  same  purpose,  be  bathed  in  glycerine  through  a  round 
speculum. 

It  may  be  mentioned  as  a  j)oint  of  practical  value,  although  not  quite 
in  place  here,  that  rectal  injections  of  glycerine  and  water  (  |  j.  to  the 
pint)  will  produce  an  alvine  evacuation,  when  every  other  form  of  enema 
has  failed.  I  have  also  fovmd  enemata  of  pure  glycerine  of  great  benefit 
in  tenesmus  and  catarrhal  proctitis. 

Emollients. — The  fluid  emollients,  such  as  the  vegetable  oils,  chiefly 
oil  of  olives  and  poppies,  are  but  little  employed  in  gynecological  practice 
at  the  present  day,  the  unctuous  substances,  especially  vasehne,  ha-\dng 
superseded  them.  However,  in  acute  vaginitis,  particularly  the  adhesive 
variety  in  old  women,  and  in  wounds  and  injuries  to  that  canal,  frequent 
bathing  of  the  vagina  with  warm  oil  through  a  speculum,  or  the  daily  in- 
troducftion  of  tampons  soaked  in  oil  may  prove  healing  and  soothing. 
There  is  no  special  advantage  in  the  oil  of  poppies,  except,  perhaps,  its 
cheapness  ;  for  it  possesses  no  narcotic  properties. 

I  shall  speak  of  the  use  of  emollient  ointments  presently,  when  I  have 
concluded  the  fluids. 

Narcotics. — The  indications  for  the  use  of  narcotic  substances  as  vagi- 
nal applications  are  contained  in  one  word — pain,  pain  in  the  pelvic  organs. 
Such  pain  may  exist  during  acute  or  chronic  inflammation,  or  as  a  symp- 
tom of  cancerous  disease.  The  absorptive  power  of  the  vaginal  mucous 
membrane  is  comparatively  slight,  but  this  property  is  vastly  increased 
when  the  epithelium  is  abraded  or  an  actual  loss  of  tissue  exists,  and  the 
absorbents  are  laid  directly  bare.  In  cancerous  ulceration,  therefore,  local 
narcotics  exert  a  much  more  beneficial  effect  than  in  areolar  hyjDerplasia 
or  pelvic  cellulitis.  And  equally  should  more  caution  be  emj^loyed  as  to 
the  dose  in  the  former  than  in  the  latter  cases.  The  inconvenience  com- 
mon to  the  employment  of  all  vaginal  tampons,  that  is,  the  difficulty  ex- 
perienced by  all  women  in  introducing  them  themselves  as  often  as  they 
should  be  used,  has  given  the  preference  to  the  application  of  narcotics, 
as  well  as  astringents  to  a  certain  extent,  in  the  form  of  suppositories, 
which,  so  far  as  narcotics  are  concerned,  may  be  either  used  per  vaginam 
or  rectum.  The  latter  method  is  generally  preferred,  because  the  greater 
absorbent  power  of  the  rectal  mucosa  renders  the  effect  a  much  more 
rapid  and  certain  one.  But  there  are  conditions  when  the  direct  applica- 
tion of  the  narcotic  to  the  cervix  seems  advisable,  and  this  is  especially 
the  case  when  a  mere  soothing,  only  mildly  narcotic  effect  is  desired,  which 
will  not  influence  the  whole  system  to  a  marked  degree.  Thus,  in  the  pel- 
vic neuralgise  of  areolar  hyperplasia  and  chronic  pelvic  cellulitis  very 
decided  comfort  can  be  afforded  the  patient  by  adding  one-half  to  one 
drachm  of  the  tincture  of  one  of  the  narcotics  (opium,  belladonna,  conium, 
hyoscyamus)  to  the  glycerine  in  which  the  tampon  is  soaked,  or  by  dip- 
ping the  cervical  end  of  the  tampon  in  the  tincture.  In  dysmenorrhea, 
too,  such  tampons,  especially  with  belladonna,  may  relieve  the  pain,  if  ap- 
plied several  days  previous  to  the  expected  flow. 

In  cervical  cancer  the  hydrate  of  chloral  in  solution  (one  drachm  to 


188  jinisroE  gynecological  MAisriPULATioisrs. 

the  ounce  of  glycerine,  or  stronger,  if  tMs  proves  insufficient)  is  not  only 
an  excellent  anesthetic  but  also  a  disinfectant.  A  tamj)on  is  soaked  in 
a  sufficient  quantity  of  the  solution  and  introduced  through  a  speculum 
up  to  the  cervix,  and  retained  there  by  a  second  dry  tampon  from  tvpelve 
to  twenty-four  hours.  This  application  is  often  the  only  local  aj)plication 
which  will  give  rehef  in  cancer  of  the  uterus,  and  it  is  free  from  the  posi- 
tive narcotic,  constij^ating,  and  disagreeable  after-effects  of  the  only  other 
rehable  narcotic  application,  morphine  suppositories.  Conium  is  sup- 
jDosed  to  have  a  specially  beneficial  effect  in  cancer,  but  I  confess  I  have 
not  been  able  to  detect  its  advantage  over  opium  or  chloral. 

The  beneficial  effect  of  iodoform,  chiefly  in  solution  with  chloral,  used 
in  this  manner',  has  already  been  referred  to. 

The  bromides  of  potassium,  ammonium,  and  sodium  may  be  em- 
ployed in  saturated  or  strong  solution  (  3  ij.  to  |j.  glycerine  and  water 
equal  parts)  on  cotton  tampons  in  those  cases  where  a  general  soothing 
effect  is  desired  quite  as  much  as  the  local  anesthesia.  Such  cases  are 
chiefly  those  of  hysteria  dej)endent  on  some  local  disease,  mainly  hyper- 
plasia uteri.  All  these  narcotic  tampons  should  be  retained  for  at  least 
twelve  and  generally  twenty-four  hours,  and  be  repeated  daily,  or  as 
often  as  necessity  may  require.  If  the  circumstances  of  the  patient  admit, 
the  regular  administration  of  local  narcotics  in  this  manner  by  the  physi- 
cian, or  by  the  patient  herself  if  she  is  dexterous  enough  to  introduce  the 
tampons  properly,  is  decidedly  preferable  to  rectal  suppositories.  Neither 
the  immediate  nor  ultimate  constitutional  effects  ai*e  so  marked  or  objec- 
tionable as  when  the  narcotic  is  absorbed  from  the  rectum. 

Disinfectants. — I  have  introduced  these  agents  into  this  section  for  the 
sole  pui-pose  of  stating  that  they  may  be  very  conveniently  and  efficaciously 
aj)plied  on  cotton,  which  is  saturated  in  a  solution  of  the  disinfectant  (1 
to  2  :  100  parts  of  water  or  glycerine  and  water),  squeezed  dry  and  intro- 
duced through  a  speculum  ;  the  tampon  is  removed  after  twenty-four 
hours.  The  use  of  disinfectants  in  this  manner  is  indicated  after  opera- 
tions on  the  uterus,  cervix,  or  vagina,  or  when  it  is  feared  that  foul  dis- 
charges from  an  open  wound  in  either  of  these  parts  may  be  absorbed. 
There  is  no  actual  advantage  in  one  of  these  agents  (carbohc  acid^  thy- 
mol, chlorinated  soda,  or  boracic  acid)  over  the  other,  although  by  reason 
of  its  want  of  odor  and  unirritating  quality,  the  boracic  acid  is  highly 
praised  by  some  gynecologists.  As  a  destroyer  of  foul  odors  the  chlori- 
nated soda,  or  plain  chlorine  water  is,  in  my  opinion,  the  most  efficient 
and  reliable.  Care  should  be  taken  to  try  the  strength  of  these  solutions 
on  the  finger  or  tongue  before  introducing  them  for  a  longer  time  into  the 
vagina,  where  they  might  easily  produce  excoriation.  The  corrosive  subli- 
mate solution  is  not  advisable  as  a  permanent  application  on  account  of  the 
danger  of  systemic  absorption. 

y.   Ointments. 

The  medicinal  agents  which  may  be  employed  rubbed  up  with  lard  or 
some  form  of  cerate  belong  either  to  the  class  of  astringents,  alteratives. 


APPLICATIONS    THROUGH    THE    SPECULUM.  189 

emollienta,  or  narcotics.  Of  the  astringents,  the  nitrate  of  silver,  tannin, 
alum,  zinc,  copj^er,  and  bismuth  may  be  employed,  best  smeared  on  tam- 
pons of  cotton  which  are  I'etained  for  twelve  to  twenty-four  hours.  The 
proportions  of  the  agent  to  the  vehicle  will  vary  from  ten  grains  to  one 
drachm  to  the  ounce.  I  am  not  aware  that  the  employment  of  these 
agents  in  ointment  form  offers  special  advantages  over  that  in  solution, 
when  a  tampon  is  soaked  in  the  fluid  and  left  in  situ  for  the  same  length 
of  time.  Certain  of  the  alteratives,  however,  are  best  employed  as  oint- 
ments, chiefly  one  which  I  have  not  yet  mentioned,  the  mercurial  oint- 
ment. In  conjunction  with  the  unguentum  potassii  iodidi(3.  Ung.  pot. 
iod.,  I  j.  ;  ung.  hydrarg.,  3  ij.)  this  ointment  is  very  beneficial  in  the  exuda- 
tions of  pelvic  cellulitis,  appHed  on  the  upper  end  of  a  conical  tamj)on  and 
retained  for  twelve  hours.  The  ointment  of  the  iodide  of  lead  (  3  ss.  to 
3  j.  to  3  j.)  may  also  be  used  in  similar  cases  in  the  same  manner. 

The  vegetable  narcotics  are  likewise  useful  in  this  manner,  the  powder 
or  solid  extract  being  rubbed  up  with  lard  or  vasehne  in  the  proportion 
of  gr.  XX.  to  3  j.  to  the  ounce,  the  strength  depending  partly  on  the  de- 
gree of  effect  desired  and  the  amount  of  ointment  applied  on  each  tampon. 
The  hydrate  of  chloral  may  also  be  rubbed  up  and  used  in  this  way. 

The  chief  utility  of  unctuous  substances,  however,  is  as  an  emollient, 
the  principal  agent  of  this  class  (the  ordinary  lard  having  been  relegated 
to  poor  practice)  being  the  modern  cosmetic  vasehne  or  cosmoline,  a 
product  of  petroleum.  It  possesses  the  great  advantage  of  not  becoming 
rancid,  is  neat  and  clean,  and  deodorant  and  disinfectant  in  itself.  I  have 
already  sung  its  praises  as  a  covering  for  the  finger  and  speculum  in  ordi- 
nary vaginal  examinations.  As  an  excipient  for  medicinal  substances  it  is 
decidedly  superior  to  the  cerates.  But  the  soothing  and  healing  j)roper- 
ties  of  vaselme  render  it  particularly  adapted  to  those  cases  of  vaginitis  in 
which  caustics  and  astringents  have  been  used  (as  solution  of  nitrate 
of  silver)  or  after  active  cauterization  of  the  cervix  (as  with  nitric  acid  or 
the  actual  cautery),  also  after  exfoliative  inflammation  or  ulceration  of  the 
vagina,  in  which  adhesions  are  to  be  prevented.  In  acute  vaginitis  an 
ointment  of  nitrate  of  silver  in  vaseline  (gr.  x.  to  xx.  to  |  j.)  may  be 
rubbed  over  the  vagina  through  a  cylindrical  speculum,  and  a  tampon  cov- 
ered with  the  same  introduced.  This  application  is  by  some  preferred  to 
the  fluid  already  described.  But,  aside  from  its  advantage  over  the  cerates 
as  a  vehicle  for  medicinal  substances,  it  is  chiefly  as  a  covering  for  tampons 
in  all  cases  where  the  hydragogue  effects  of  glycerine  are  not  desired  that 
vaseline  is  employed.  It  is  always  fresh  aiad  clean,  and  keeps  indefinitely. 
If  desired,  its  antiseptic  properties  may  be  enhanced  by  rubbing  up  five 
to  ten  grains  of  carbolic  or  boracic  acid  or  thymol  with  it,  and  this  is 
an  excellent  precaution,  above  all  in  obstetric  practice.  At  a  warm 
temperature  it  becomes  liquid,  and  this  fact  should  be  borne  in  mind 
when  rapidly  removing  it  from  the  vessel,  lest  it  drop  on  the  floor  or 
clothes.  There  can  be  no  doubt  that  vaseline  will  soon  entirely  super- 
sede the  ancient  cerates,  if  it  has  not  already  done  so  in  this  country. 
Certainly  the  necessity  of  writing  a  special  article  on  the  excellencies  of 


190  MINOR    GYNECOLOGICAL    MANIPULATIONS. 

this,  substance  in  gynecology,  as  was  done  in  France  by  Sinety,  has  not  oc- 
curred to  any  of  our  specialists,  who  have  used  it  freely  since  its  intro- 
duction. 

It  is  abundantly  apparent,  from  the  manner  in  which  these  ointments 
are  to  be  used — namely,  on  cotton  or  wool  tampons — that  they  are  to  be 
introduced  through  the  speculum,  whether  round,  bivalve,  or  Sims  is  en- 
tirely immaterial.  The  patient  herself  may  be  able  to  do  this  without  a 
speculum,  if  the  vaginal  orifice  is  patulous  and  she  sufficiently  dexterous. 
In  large  gaping  vaginae,  as  in  prolapsus,  a  tampon  covered  with  lard  or  vase- 
line may  be  rolled  in  tannin,  or  alum  and  sugar,  powder  and  pushed  up 
by  the  patient  herself,  to  be  renewed  every  day.  Very  good  results  have 
been  obtained  in  prolapsus  by  this  method. 

Ointments,  if  melted,  may  be  injected  into  the  vagina  through  a 
syringe,  one  of  hard  rubber  or  glass  being  best  used  for  the  purpose.  I 
have  thus  found  it  convenient  to  inject  melted  vaseline  as  an  emollient  in 
a  case  of  accidental  cauterization  of  the  vagina  with  chromic  acid,  and 
puerperal  injury  of  the  cajial  might  afford  an  indication  for  the  same  ap- 
plication. The  syringe  need  not  hold  more  than  one  ounce  and  should 
have  a  nozzle  at  least  two  inches  long.  Medicated  ointments  are  not  used 
in  this  manner,  since  their  fluidity  will  prevent  their  retention  and  ab- 
sorption. 

There  may  be  other  medicinal  substances  which  have  been  used  as 
local  applications  to  the  cervix  and  vagina  by  this  or  that  practitioner  in 
this  or  that  country.  It  would  obviously  be  next  to  impossible  to  collect 
all  the  various  agents  which  have  thus  been  employed  at  different  times. 
Such  as  have  made  for  themselves  a  reputation,  great  or  small,  I  have  en- 
deavored to  mention,  and  trust  I  have  omitted  none  of  importance.  There 
is  still  one  agent,  largely  used  internally,  per  rectum,  vaginam,  and 
uterum,  and  hypodermically,  which  has  also  been  emj)loyed  by  some  as  a 
local  application  to  the  cervix.  It  is  ergot,  either  as  fluid  extract  on  cotton 
(with  or  without  glycerine),  or  as  ointment.  Dr.  Dabney  reports  having 
used  with  success  in  cervical  hypei'plasia  the  foUewing  preparation  painted 
twice  daily  on  the  cervix  :  I^ .  Ergotin,  gr.  xx.  ;  tr.  iodii,  fl.  3  j-  ;  glyce- 
rinse,  q.  s.  ad  3  j.  M.  Or  the  following  applied  on  saturated  cotton  and 
inserted  into  the  vagina  at  bedtime  :  IJ.  Ergotin,  or  Squibb's  ext.  sq., 
3  ss.  ;  extr.  belladonuse,  gr.  vi.  ;  aquse,  glycerinee,  aa  3  iv.  M.  To  be  re- 
moved next  morning. 

I  have  never  employed  ergot  in  this  manner,  believing  the  absorbent 
property  of  the  covering  of  the  infravaginal  portion  of  the  cervix  and  the 
vaginal  canal  to  be  too  slight  to  expect  great  benefit  from  this  drug  so 
^applied.  Still  I  have  stated,  under  Narcotics,  that  such  absorption  un- 
doubtedly takes  place  to  a  certain  extent,  the  more  the  larger  the  surface 
to  which  the  agent  is  applied  ;  and  that  this  absorption  is  greatly  increased 
by  abrasion  of  the  epithelium.  I  do  not  therefore  deny  that  ergot  may 
act  beneficially  in  this  manner,  although  I  should  expect  much  more  de- 
cided effect  from  it  if  applied  in  rectal  or  uterine  suppositories. 


VAGII^AL    SUPPOSITORIES.  191 


S.    Vaginal  Suppositories. 

Any  of  the  solid  mineral  substances  enumerated  above  can  be  nibbed 
up  with  the  excipient  ordinarily  employed  for  the  purpose,  cocoa-butter, 
and  employed  in  the  form  of  suppositories.  These  may  be  made  either 
with  the  fingers  or  by  being  cast  into  moulds  (in  which  case  the  medicine 
is  stirred  into  the  melted  butter),  or  much  better  by  pressure  in  a  mould- 
machine,  the  melted  butter  with  the  medicine  rubbed  ujd  with  it  being 
put  dry  into  the  mould.  The  latter  suppositories  are  much  smoother  and 
more  compact  and  regular  than  those  made  by  the  fingers  or  cast  in 
moulds,  and  possess  the  advantage  of  not  having  been  heated,  whereby 
their  medicinal  property  might  have  been  changed.  These  facts  apply 
equally  to  vaginal  and  rectal  suppositories.  Vaginal  suppositories  are,  as 
a  rule,  made  about  twice  the  size  of  rectal,  containing  at  least  one  drachm 
of  cocoa-butter  to  barely  one-half  drachm  for  the  rectal.  They  are 
smoothly  pyramidal  in  shape,  the  pointed  end  being  first  introduced. 
Rectal  sujipositories  are  frequently  made  conical,  like  a  lead-jDcncil,  and 
are  then  introduced  with  a  piston-tube.  I  have  not  succeeded  in  discover- 
ing the  advantage  of  this  method  of  inserting  them,  having  found  it  more 
difficult  to  induce  patients  to  introduce  the  tube  than  to  push  the  round 
pyramid  of  a  suppository  into  the  rectum  with  the  finger.  By  oiling  or 
wetting  the  suppository  its  introduction  is  greatly  facilitated. 

Suppositories  (vaginal  and  rectal)  are  also  made  of  gelatine,  being  cast 
in  moulds  of  different  sizes.  This  form  of  suppositoiy  was  largely  intro- 
duced by  Floclvhart  &  Clarke,  druggists,  of  Edinburgh,  who  made  them 
ait  wholesale  ;  but,  on  account  of  the  numerous  moulds  and  greater  care 
required,  and  the  absence  of  any  positive  advantage  over  those  of  cocoa- 
butter,  they  have  not,  to  my  knowledge,  become  popular  in  this  country. 
All  the  mineral  substances  used  for  vaginal  applications  can  be  combined 
in  solution  with  the  gelatine  suppositories,  and  also  some  of  the  fluid  sub- 
stances used  for  the  same  purpose,  which,  it  is  true,  is  an  advantage  over 
the  butter  plugs,  with  which  fluids  cannot  be  combined.  Solid  gelatine 
suppositories,  however,  require  to  be  kept  in  air-tight  bottles,  as  when  dry 
and  hard  they  do  not  readily  dissolve.  Soluble  gelatine  capsules  contain- 
ing a  certain  quantity  of  the  agent  to  be  employed  have  also  been  manu- 
factured. The  best  preparations  of  medicated  gelatine  which  I  have  met 
with  are  made  by  Robert  E.  Fleischer,  pharmacist,  of  No.  652  Sixth  Street, 
New  York,  who  has  made  a  specialty  of  the  manufacture  of  gelatine  sup- 
positories and  bougies  for  the  vagina,  rectum,  uterus,  urethra,  etc.,  with 
ingredients  and  proportions  to  order.  I  know  by  experience  that  his 
preparations  do  not  harden  when  kept.  Of  the  medicinal  agents  employed 
locally  in  various  affections  of  the  cervix  and  vagina,  those  apjDlied  in  the 
form  of  suppositories  are :  Astringents :  Tannin,  alum,  sulphates  of  zinc 
and  copper,  acetate  of  lead,  nitrate  of  silver,  nitrate  of  aluminium.  Alter-- 
atives :  Iodine,  iodide  of  potash,  iodide  of  lead.  Nai'cotics :  Extract  of 
opium,   belladonna,   conium,   stramonium,    and   hyoscyamus,    hydrate   of 


192  MIlSrOR    GYNECOLOGICAL    MANIPULATIONS. 

cKloral,  iodoform,  bromides  of  potash,  ammonium,  and  sodium.  Disin- 
fectants :  Carbolic  acid,  thymol,  boracic  acid., 

A  combination  of  these  agents  is  often  beneficial ;  thus  a  disinfectant 
or  narcotic  may  be  added  to  an  astringent  or  alterative  if  the  discharge  be 
offensive  or  pain  exist,  or*  two  astringents  (as  the  sulphates  of  zinc  and 
copper),  or  two  or  more  narcotics  (as  a  bromide  and  chloral,  with  a  nar- 
cotic extract)  may  be  combined  in  the  same  suppository.  It  is  always  a 
good  plan  to  counteract  any  pain  which  may  be  caixsed  by  an  altei'ative  or 
astringent  by  the  addition  of  a  mild  narcotic.  In  cases  where  the  nar- 
cotic effect  is  the  one  chiefly  to  be  desired,  as  in  vaginismus,  a  bromide 
and  a  narcotic  extract  (ammonii  bromid.,  gr.  x.,  extr.  belladonnae  or  stra- 
monii,  gr.  ij.  to  v.)  act  best  together  ;  where  a  disinfectant  influence  is 
called  for  with  the  narcotic  effect,  as  in  carcinoma,  the  hydrate  of  chloral 
alone,  or  the  extract  of  conium,  gr.  iij.,  with  thymol,  or  boracic  or  car- 
bolic acid,  one  to  two  grains  to  the  suj^pository,  make  an  excellent  combi- 
nation. The  general  indications,  already  repeatedly  referred  to  as  govern- 
ing the  use  of  all  these  drugs  in  special  cases,  will  influence  their  selection, 
dose,  combination,  and  repetition  in  this  form  as  well. 

The  quantity  of  each  of  the  astringent  and  alterative  agents  to  be 
used  in  each  vaginal  suppository  varies  from  5  to  10  grains  ;  that  of  the 
narcotics  from  1  to  3  grains  of  the  extracts  ;  10  to  30  grains  of  the 
hydrate  of  chloral  and  bromides,  and  5  to  10  grains  of  the  iodoform  ; 
that  of  the  disinfectants  1  to  2  grains,  each  suppository  containing  at  least 
1  drachm  of  cocoa-butter  or  gelatine,  or  2  drachms  if  the  vagina  is  very 
capacious. 

The  suppositories  are  introduced  at  night  when  the  patient  is  in  bed, 
opportunity  thus  being  given  for  their  active  agents  to  be  absorbed  or 
exert  their  local  effect  before  the  patient  rises  and  the  melted  excipient 
escapes  from  the  vagina.  If  it  is  desired  to  confine  the  action  of  the  sup- 
positories chiefly  to  the  upper  portion  of  the  vagina  and  the  cervix,  it  is 
well  to  introduce  a  glycerine  tampon  immediately  after  the  suppository. 
This  is  a  good  plan  with  the  alterative  suppositories  and  those  from  which 
a  direct  anesthetic  effect  is  desired  on  the  cervix.  A  cleansing  or  hot 
injection  (according  to  necessity)  is  to  be  used  on  the  next  morning.  It 
is  always  well  to  avoid  joossible  oozing  from  the  vagina,  to  direct  the  pa- 
tient to  wear  a  genital  cloth  during  the  night,  after  having  introduced  a 
suppository. 

In  virgins  in  whom  the  hymen  interferes  with  the  introduction  of  a 
speculum  and  the  direct  application  of  medicines  to  the  cervix  and  vagina 
otherwise  than  by  weak  injections,  these  suppositories  form  a  very  con- 
venient means  of  applying  stronger  agents  when  such  are  indicated.  This 
is  frequently  the  case  in  chronic  leucorrhea  and  cervical  erosion.  Their 
greatest  advantage  is  their  introduction  by  the  patients  themselves.  In 
this  way  the  certainly  more  thorough  and  therefore  more  effectual  ajopli- 
cation  of  the  agent  by  the  physician,  after  one  of  the  methods  already  de- 
scribed, can  be  limited  to  intervals  of  once  a  week  or  less,  and  much 
trouble  and  expense  be  saved  the  patient.     Also,  a  milder  application  can 


APPLICATIONS    THROUGH    THE    SPECULUM.  193 

thus  be  kept  up  during  the  interval  between  the  strong  measures.  I  thus 
frequently  give  patients  with,  hj'perplasia  uteri  and  cellulitic  deposits  sup- 
positories of  iodide  of  lead  or  iodoform  to  inti-oduce  every  night,  while  I 
make  the  more  powerful  application  of  tincture  of  iodine  but  once  a  week, 
and  thus  keep  up  a  steady  alterative  action  and  get  good  results.  It 
should  be  added  that  the  unpleasant  odor  of  the  iodoform  is  best  neutral- 
ized in  suppositories  by  adding  one  or  two  grains  of  thymol,  or,  in  default 
of  this,  five  grains  of  tannin  to  each  suppository. 

But  a  comparatively  small  number  of  remedies  act  better  by  the  va- 
gina than  by  the  rectum,  hence  the  following  list  is  much  shorter  than 
generally  given.  It  contains  only  articles  intended  to  act  on  the  vaginal 
mucous  membrane  or  cervix,  and  not  on  the  general  system,  which  is  much 
more  easily,  thoroughly,  and  safely  reached  through  the  rectum. 

Borax Cicatrizing, 

Tannin Astringent, 

Alum " 

Acetate  of  lead " 

Acetate  of  lead  and  opium "  * 

Sulphate  of  zinc " 

Iodide  of  lead Alterative  and  resolvent, 

Iodide  of  potassium "  " 

Mercurial  ointment "  " 

Iodoform "  " 

Bromide  of  potassium Local  anestlietic, 

Carbolic  acid , , Disinfectant, 

Borate  of  soda Antacid, 

Numerous  other  agents  and  combinations  prepared  by  manufacturers 
are  of  hypothetical  value  and  partake  of  the  nature  of  "  fancy  "  prepara- 
tions. 

e.   Insufflation. 

Any  powder  may  be  blown  into  the  vagina  and  against  the  cervix. 
But,  of  course,  it  is  admissible  to  use  only  such  agents  in  this  manner, 
the  action  of  which,  when  left  in  contact  with  the  mucous  membrane  for 
some  time,  is  not  injurious.  The  strong  styptic,  caustic,  and  astringent 
powders,  such  as  the  salts  of  iron,  pure  alum,  sulphates  of  zinc  and  copper, 
should  not  be  used  in  this  way.  But  tannin,  alum  and  sugar,  or  alum 
with  starch  or  powdered  slippery-elm  bark  (equal  parts),  or  iodoform,  or 
tannin  and  iodoform,  or  bismuth,  will  be  very  beneficial  when  applied  in 
this  manner.  The  powdered  tannin  and  the  diluted  salts  of  alum  and 
zinc,  and  iodoform,  with  or  without  tannin,  are  most  indicated.  The 
chief  advantage  of  insufilation  is  that  the  patients  can  do  it  themselves 
by  means  of  a  slender  metal  tube  with  a  tip  perforated  by  many  small 
holes,  through  which  the  powder  is  projected  by  a  rubber  bulb  at  the 
other  end.  A  homely  and  inexpensive  contrivance  of  the  sort  is  the  or- 
dinary insect-powder  bellows.  An  objection  is  the  ready  clogging  of  the 
mouth  of  the  tube  by  the  moist  powder,  which  may  prevent  the  spray 
after  the  first  trial.  But  this  can  be  avoided  by  careful  cleansing.  For 
13 


15  grains. 
10       " 

10 
10 

5 

( 

10 

< 

5 

( 

10 

( 

5 

( 

3  to 

10  grains. 

30  grains. 

5 

' 

20 

I 

194 


MINOR    GYNECOLOGICAL    MANIPULATIONS. 


the  use  of  the  physician  the  insufflator  possesses  no  particular  advantage, 
since,  if  an  examination  has  to  be  made,  the  powder  can  more  easily  and 
quite  as  effectually  be  apphed  to  the  vagina  and  cervix  by  being  placed  in 
__  the  cyUndrical  speculum  with  a  spoon  or  spatula. 

Through  the  Sims  speculum,  however,  an  in- 
sufflator is  convenient.  And  in  one  respect  this 
instrument  is  preferable  to  the  spatula  in  that 
an  excess  of  the  powder  is  not  applied,  a  matter 
of  importance  with  some  agents,  such  as  iodo- 
form, which  irritate  locally  and  produce  toxic 
constitutional  effects  if  too  freely  used.  A  pro- 
tecting cloth  should  always  be  worn  to  jDrevent 
the  powder  dissolved  in  the  vaginal  mucus  from 
oozing  over  the  labia,  and  producing  smarting 
or  soiling  of  the  hnen. 

V.    TAMPONADE  OF  THE  VAGINA. 

The  vaginal  tampon  is  employed  for  various 
purposes,  the  chief  of  which  are :  1,  as  a  carrier 
for  the  apphcation  of  medicinal  agents  to  the  cer- 
vix and  vagina ;  2,  as  a  means  of  retaining  certain 
substances  introduced  into  the  uterus  in  their 
proper  position — such  as  pledgets  of  cotton,  lami- 
naria  and  sponge-tents,  stem-pessaries;  3,  as  a 
means  of  retaining  the  utenis  itself  in  its  normal, 
or  some  other  position  which  it  is  desired  to  give 
to  it,  as  in  displacements,  and  as  a  means  of  pre- 
venting a  relapse  of  a  prolapsed  ovaiy ;  4,  as  a 
mechanical  support  and  stimulus  to  the  pelvic  ves- 
sels, and  an  alterative  to  the  pelvic  tissues  by 
means  of  the  direct  pressure  it  exerts  on  them ; 
5,  as  a  protective  to  the  ulcerated,  inflamed  or  swollen  ceiwix  or  vaginal 
walls,  to  prevent  friction  and  an  increase  of  irritation  ;  6,  as  a  means  of 
dilating  or  separating  the  vaginal  walls — a  substitute  for  a  hard  or  disten- 
sible dilator — in  constriction  of  the  vaginal  canal,  after  operation  for 
vaginal  atresia  or  stenosis,  in  vaginismus  and  spasm  of  the  levator  ani  mus- 
cle ;  7,  as  a  hemostatic  by  its  mechanical  jDressure  and  size  (the  action  of 
the  tampon  is  really  by  virtue  of  its  dilatation  of  the  vaginal  pouch,  and 
this  section  might,  therefore,  properly  be  combined  with  Nos.  4  and  5 ; 
still,  the  great  importance  of  this  use  of  the  tampon  leads  me  to  discuss  it 
sexDarately) ;  8,  as  an  absorbent  of  vaginal  and  uterine  discharges,  which 
are  thus  prevented  from  touching  the  external  and  sound  parts,  and  as  a 
protective  to  the  sound  parts  from  caustic  substances  apphed  to  the  uterus 
or  the  cervix.  Several  tampons  may  be  employed  for  different  purposes 
at  the  same  time  in  the  same  case,  as  when  it  is  desired  to  retain  the 
uterus  in  a  certain  position  while  the  first  tampon  is  applied  over  the  cer- 


FiG.  90. — Powder  Insufflator. 


TAMPONADE  OF  THE  VAGINA.  195 

vix  to  keep  a  laminaria,  or  stem,  or  cotton  pledget  in  place ;  and  several 
objects  may  be  intended  by  the  same  tampon  at  once,  when  a  protecting 
and  dilating  influence  are  desired  at  the  same  time,  or  a  hemostatic  effect 
is  added  to  either  of  these,  or  an  astringent  is  combined  with  a  supporting 
effect. 

1.  As  a  carrier  for  the  application  of  medicinal  agents  to  the  cervix  and 
vagina. 

In  the  preceding  pages  frequent  mention  has  been  made  of  the  intro- 
duction of  medicinal  agents  into  the  vagina  and  against  the  cervix,  on  pledg- 
ets of  cotton  or  wool,  so-caUed  "tampons."'  But  neither  the  substance 
of  these  tampons  nor  the  details  attending  theii'  use,  and  the  annoyances 
and  even  danger  following  their  abuse,  have  been  discussed.  A  descrip- 
tion, therefore,  of  the  manufacture  and  employment  of  medicated  tam- 
pons in  all  the  minor  practical  details,  is  in  order.  Many  of  these  minu- 
tiae may  seem  trivial  or  frivolous  ;  but  so  little  is  said  about  these  matters 
in  the  ordinary  text-books,  and  even  the  smallest  details  may  prove  valua- 
ble and  save  annoyance,  that  I  feel  sure  the  beginner  will  appreciate  the 
object  intended  in  these  pages.  The  material  preferred  for  the  manu- 
facture of  tampons  is  generally'  cotton,  as  it  comes  in  rolls  or  sheets, 
preferably  the  former.  It  is  not  necessary  to  use  the  purified,  so-called 
"absorbent"  cotton  for  tampons,  unless  a  special  degree  of  absorption  of 
the  fluid  or  an  esthetic  effect  is  desired ;  the  absorbent  cotton  is  used 
mainly  as  a  vehicle  for  intra-uterine  applications.  Some  gynecologists  pre- 
fer tow,  plain  or  carbolized,  and  Dr.  Skene,  of  Brooklyn,  is  very  enthusi- 
astic in  his  advocacy  of  a  refined  preparation  of  that  article  known  as 
"  marine  lint "  for  tampons.  The  disinfectant  property  of  the  tow  is  no 
doubt  an  advantage,  but  its  bro^vn  color  has  always  made  it  objectionable 
to  me,  both  as  a  substance  for  tampons  and  for  vulvar  pads  in  the  lying- 
in  chamber  ;  this  color  prevents  the  appearance  and  character,  and  the  tar- 
smell  the  odor,  of  the  discharges  from  being  clearly  ascertained,  and  thus 
removes  a  valuable  diagnostic  auxiliary.  It  is  for  this  reason,  also,  that 
I  prefer  the  plain  white  cotton  as  a  mop  in  the  dressing-forceiDS  to  sponges 
on  holders  or  to  tow  in  the  ordinary  cleansing  manipulations  of  the  cervix 
during  a  specular  examination. 

Accordingly  as  it  is  desired  to  keep  the  medicinal  agent  in  contact  with 
the  cervix  alone,  or  to  place  it  against  the  vaginal  walls,  the  tampon  is  dif- 
ferently shaped  and  constructed.  When  a  tampon  is  to  be  merely  soaked 
in  glycerine,  or  some  glycerole  (as  of  tannin  or  iodoform),  or  a  dry  powder 
is  to  be  placed  against  the  cervix,  the  tampon  is  made  as  shown  in  Fig.  91. 
the  cotton  being  flattened  into  a  disk  about  two  inches  in  diameter  and 
one-sixth  of  an  inch  thick,  Avith  a  string  loosely  tied  about  its  middle  so 
as  to  constrict  it  but  slightly.  But,  if  a  patient  wearing  one  of  these  disk 
tampons  is  to  move  about,  it  will  generally  be  advisable  to  support  this 
tampon  by  another  of  a  cylindrical  shape,  especially  if  the  disk  be  soaked 
in  a  fluid  liable  to  escape  from  the  vagina  and  stain  the  linen.  The  cylin- 
drical tampon  is  made  by  rolling  a  handful  of  cotton-wool  tightly  together 
to  the  required  size  and  shape,  and  tying  a  stout  twine  firmly  around  its 


196 


MINOE    GYNECOLOGICAL    MANIPULATIONS. 


middle.  It  is  always  convenient  and  time-saving  to  prepare  these  tampons 
in  bulk  and  keep  a  supjD^y  on  hand,  A  number  of  cylindrical  tampons  are 
rapidly  made  by  spreading  out  the  whole  roll  of  cotton  (which  often  comes 
in  loosely  compressed  sheets,  but  ungiazed,  remember  ;  the  glazed  cotton 
does  not  absorb  well),  and  then  rolUng  it  up  again  tightly,  as  one  rolls  a 
roller-bandage,  until  the  desired  thickness  is  reached.  This  rope  of  cot- 
ton, which  is  about  two  feet  long,  is  then  detached  from  the  remainder  of 
the  bundle,  and  twine  is  tied  tightly  around  it  at  intervals  of  two  inches, 
beo'inning  and  ending  about  one  inch  from  either  end.  The  roll  is  then  cut 
thi'ouo-h  between  the  twines,  and  a  certain  number  of  cylindrical  tampons 
two  inches  in  length  by  one  inch  thick  are  obtained  (Fig.  92).  This  is 
about  the  size  of  the  ordinary  tampon  as  applicable  to  vaginae  of  normal 
width ;  in  abnormally  distended  vaginte,  or  where  it  is  intended  to  dis- 
tend the  canal  (as  in  hemorrhage)  the  size  of  the  tampon  should  be  pro- 
portionately increased.  If  the  vaginal  j^ouch  is  to  be  tamponed,  the  tam- 
pon should  be  round  like  a  ball,  of  the  size  of  an  English  walnut,  and  not 


Fig.  91.— Flat  Disk  Tampon. 


Fig.  92.— Solid  Cylindrical  Tampon. 


too  tightly  Wrapped,  so  that  it  may  adapt  itself  to  the  shape  of  the  pouch. 
But  a  cylindrical  tampon  may  also  be  used  for  this  purpose,  being  laid 
crosswise  into  the  pouch.  It  is  not  superfluous  to  mention  that  the  twine 
should  be  sufficiently  strong,  so  as  not  to  break  when  the  patient  attempts 
to  remove  the  tampon,  and  long,  so  that  it  does  not  slip  within  the  vagina 
and  thus  evade  the  patient's  fingers.  It  is  very  disagreeable  to  be  called 
to  remove  a  tampon  the  cord  of  which  has  broken  or  cannot  be  reached, 
particularly  if  that  tampon  has  become  offensive,  as  it  generally  does 
within  forty-eight  hours.  And  the  removal  of  such  a  tampon  is  by  no 
means  an  easy  task,  being  perhaps  impossible  by  the  fingers  alone  if  it 
caiTied  an  astiingent.  Even  with  the  long  dressing-forceps  it  is  an  un- 
pleasant and  tedious  matter  to  grasp  the  compressed  and  slippery  cotton 
without  inadvertently  seizing  the  vaginal  wall  in  the  forceps.  I  have 
found  that  by  introducing  two  fingers  and  hooking  them  above  the  tam- 
pon, its  removal  is  much  facilitated  in  a  roomy  vagina.  But  where  the 
vagina  is  narrow  or  the  tampon  large,  it  will  be  found  much  the  best  j^lan 
to  put  the  patient  on  th3  side,  introduce  a  Sims  speculum,  or  use  the  first 


TAMPONADE    OF    THE    VAGIjSTA.  197 

two  fingers  of  tlie  left  hand  as  a  substitute  and  expose  the  tampon,  before 
attempting  to  remove  it  with  the  forceps. 

'  The  twine  depending  from  the  tampon  should  be  about  eight  inches 
long,  so  as  to  protrude  some  two  or  three  inches  from  the  vagina.  Strong 
white  twine  is  the  variety  generally  employed. 

One  rule  it  is  very  important  to  bear  in  mind  in  connection  with  the 
use  of  tampons,  viz.  :  never  to  omit  to  tell  a  j)atient  that  she  has  such  an 
article  in  her  vagina,  and  that  she  is  to  remove  it  by  the  string  within  a 
given  time.  My  nurse  has  strict  orders  always  to  remind  patients  again 
before  they  leave,  of  the  presence  of  the  tampon,  and  that  it  must  be  re- 
moved within  twenty-four  hours.  It  is  also  well  to  impress  upon  them  not 
to  use  too  much  or  sudden  force  in  traction  on  the  cord,  for  fear  of  bi*eak- 
ing  it,  and  that  traction  should  be  made  downward  toward  the  perineum, 
the  fingers  grasping  the  cord  as  close  to  the  vulva  as  possible.  Tampons 
should  generally  be  removed  after  twenty-four  hours.  If  allowed  to  re- 
main longer,  they  are  very  liable  to  become  oflfensive,  even  when  carbolized. 
This  is  especially  the  case  when  a  number  of  tampons  have  been  intro- 
duced for  uterine  hemorrhage  and  left  untouched  for  forty-eight  hours,  as 
is  frequently  necessary  in  dispensary  practice  ;  the  blood  gradually  saturates 
the  cotton,  decomposes,  and  the  tampons,  in  spite  of  carbohzation,  are  ex- 
ceedingly offensive  when  removed.  When  circumstances  permit,  in  such 
cases,  it  is  advisable  to  renew  the  tampons  every  day,  even  at  the  risk  of 
re-exciting  the  hemorrhage.  It  is  not  practicable  to  carbolize  the  tampons 
so  strongly  as  to  effectually  prevent  decomposition,  since  the  acid,  together 
with  the  pressure,  would  excoriate  the  vagina.  In  this  respect  the  other 
disinfectants,  chiefly  solution  of  thymol,  are  preferable,  since  they  can  be 
used  in  a  more  concentrated  solution  without  cauterizing.  In  removing 
tampons,  when  a  number  have  been  introduced,  care  should  be  taken  not 
to  overlook  one  ;  I  have  seen  a  chill  and  rise  of  temperature  simulating 
septicemia  follow  the  accidental  retention  of  a  small  tamjDon  soaked  in  a 
dilute  solution  of  the  chloride  of  iron,  in  a  case  of  amiDutation  of  the 
cervix,  symptoms  which  at  once  subsided  when  the  tampon  was  detected 
and  removed  and  the  vagina  washed  out.  It  is  therefore  advisable  to  re- 
move a  batch  of  tampons,  even  when  supplied  with  traction-cords,  with  for- 
ceps through  a  Sims  speculum,  rather  than  trust  to  withdrawing  them 
by  the  cords,  and  to  make  note  of  the  number  of  pledgets  introduced.  I 
shall  explain  farther  on  why,  as  a  rule,  a  column  of  tampons  should  be  in- 
troduced and  removed  only  through  the  Sims  by  the  physician,  and  cords 
are  therefore  not  required. 

I  have  already  mentioned  that  other  substances  than  cotton,  such  as 
oakum,  or  marine  lint,  or  wool,  may  be  used  for  tampons.  "Where  a  mere 
disinfectant  effect  is  desired,  the  tow,  especially  if  carbolized,  is  superior 
to  cotton  ;  where  an  expansive  elasticity  is  called  for,  as  in  fixing  the 
uterus  or  dilating  the  vagina,  the  wool  excels  either  cotton  or  tow.  Prac- 
tically, cotton  answers  every  purpose  if  property  prepared,  and  being  most 
easily  procurable,  is  undoubtedly  inost  popular.  Sponges  are  also  used 
as  tampons,  as  well  as  English  lint-sheeting  rolled  into  the  required  shape 


198  MINOR    GYNECOLOGICAL    MANIPULATIONS. 

and  size.  Sponges  answer  very  well  when  the  patient  herself  is  to  intro- 
duce the  tampon  soaked  in  pure  glycerine  or  some  astringent  or  disinfect- 
ant solution  in  glycei'ine,  or  covered  with  some  ointment.  But,  as  a  rule, 
it  is  best  to  throw  away  the  tampon  and  replace  it  by  a  fresh  one  every 
day,  for  it  is  hable  to  become  foul,  no  matter  how  carefully  it  is  cleansed  ; 
and  this  would  obviously  be  rather  expensive  with  sponges.  The  same  ob- 
jection applies  to  English  lint,  which  absorbs  fluids  very  rapidly  and  thor- 
ouo-hlv,  and  forms  an  excellent  tampon.  A  very  plausible  substitute  for 
these  substances  is  recommended  by  Dr.  Frank  P.  Foster,  of  New  York, 
in  the  shape  of  ordinary  lampwicking,  which  is  cheap,  abundantly  absorb- 
ent, and  resilient.  Dr.  Foster  introduces  the  wicking  through  a  speculum, 
packing  in  with  the  forceps  strip  after  strip  of  the  unwound  wicking  (it 
comes  wound  in  balls)  until  the  vagina  is  filled.  The  wicking  is  then  cut 
off  some  two  or  three  inches  from  the  vulva,  the  tampon  supported  by  fin- 
ger or  forceps,  and  the  speculum  withdrawn.  The  great  advantage  of  this 
wickiug-tampon,  according  to  Dr.  Foster,  is  that  the  patient,  by  pulling 
on  the  piece  projecting  from  the  vulva,  can  remove  the  whole  mass  by 
simply  unwinding  it  inch  b}'  inch  ;  therefore,  neither  in  introduction  nor 
removal  has  a  large  mass  to  pass  and  distend  the  vaginal  orifice.  I  have 
not  had  occasion  to  employ  this  tampon,  but,  judging  from  the  description, 
am  very  favorably  impressed  by  it,  especially  in  cases  where  it  is  neces- 
sary to  introduce  a  number  of  tampons  the  removal  of  which  the  patient 
herself  is  to  accomplish.  This  is  frequently  the  case  with  patients  living 
at  a  distance,  in  whom  the  supportiDg,  dilating,  or  hemostatic  tamponade 
is  required.  I  have  ah-eady  referred  to  the  difficulty  of  removing  such  a 
multiple  tampon,  except  with  the  forceps  through  a  speculum.  If  a  num- 
ber of  separate  tampons  are  introduced,  each  with  its  string  attached,  and 
the  patient  is  told  to  remove  them  herself,  the  multiplicity  of  cords  renders 
it  impossible  for  her  to  know  which  tampon  to  remove  first,  and  she  may 
quite  as  well  attempt  to  withdraw  the  uppermost  one  first  as  the  lowest, 
and,  if  she  does  this,  will  either  fail  entirely  or  drag  the  whole  mass  through 
a  vaginal  orifice  perhaps  large  enough  only  to  admit  one  tampon  at  a  time. 
This  occuiTcnce  may  be  avoided  by  attaching  strings  of  different  color  or 
length  to  the  several  tampons,  the  patient  making  note  of  the  order  in 
which  to  pull  on  these  strings,  or  making  knots  to  each  string — one  knot 
for  the  first  tampon  to  be  removed,  two  for  the  second,  and  so  on.  I  have 
endeavored  to  overcome  this  difficulty  (which,  however,  really  comes  into 
play  only  when  the  vaginal  orifice  is  narrow,  for  a  gaping  vulva  offers  no 
obstacle  to  the  removal  of  even  a  large  mass  of  tampons)  by  introducing 
first  a  large  flat  tampon  with  a  stout  cord,  which  filled  the  whole  vaginal 
pouch,  and  then  placing  smaller  flat  tampons  without  cords  against  this, 
so  that  traction  on  the  one  string  would  remove  all  the  tampons  together. 
It  must,  however,  be  remembered  that  occasonaUy  a  tampon  may  be  left 
behind  in  this  manner,  an  occurrence  to  be  detected  by  remembering  the 
number  of  pledgets  introduced  and  counting  them  on  their  removal.  As  a 
rule,  whenever  it  is  necessary  to  introduce  a  number  of  tampons  at  the  same 
time  (which  is  chiefly  the  case  in  hemori-hage  and  uterine  displacement) 


TAMPONADE    OF    THE    VAGINA.  199 

it  is  worth  the  while  of  both  patient  and  physician  to  introduce  and  re- 
move them  properly,  that  is,  with  forcej^s  through  the  Sims  speculum,  and 
cords  therefore  are  not  required. 

The  old-fashioned  kite-tail  tampon,  where  a  number  of  pledgets  are  tied 
one  after  the  other  on  one  string,  by  which  they  are  removed,  is  certainly 
useful  when  nothing  better  presents. 

The  lamp- wick  tampon  of  Dr.  Foster  is  merely  an  improvement  (chiefly 
through  the  porosity  and  firmness  of  the  wicking)  on  the  old  tampon  of 
long  strips  of  linen  or  calico,  which,  after  being  boiled,  were  soaked  in  the 
fluid  to  be  used  for  the  occasion  and  packed  into  the  vagina  ;  they  were 
withdrawn  by  the  piece  allowed  to  protrude,  precisely  like  the  mcking.  A 
tampon  which  was  highly  lauded  and  really  is  excellent  in  cases  of  hem- 
orrhage, chiefly  during  miscarriage,  is  the  ordinary  roller-bandage,  which  is 
introduced  either  through  or  without  a  speculum,  the  central  portion  being 
pushed  upwai'd  by  the  finger  as  soon  as  the  roller  touches  the  cervix,  and 
13lugging  that  canal.  In  this  Avay  not  only  the  vagina,  but  also  the  cervix, 
are  tamponed.  It  is  removed  by  the  tail  of  the  bandage,  which  is  left 
hanging  from  the  vagina.  This  bandage  may  be  medicated,  but  its  use  is 
chiefly  adapted  to  cases  of  hemorrhage.  Ordinary  picked  linen  lint,  such 
as  is  used  largely  in  surgical  practice,  is  no  longer  employed  for  vaginal 
tampons.  It  is  too  coarse,  stringy,  and  not  sufficiently  cohesive.  For 
hemorrhage,  dilatable  rubber-bags  (so-called  colpeurynters),  or,  for  want 
of  anything  better,  an  ox  or  pig's  bladder,  form  excellent  tampons.  For 
purposes  of  medication  they  are  useless. 

I  have  already  stated  that  ordinary  loosely  picked  cotton-wool,  as  it 
comes  in  rollers  two  feet  long  by  six  inches  wide,  is  that  commonly  used 
and  perfectly  satisfactorily  for  tampons.  The  refined,  bleached  cotton -wool, 
from  which  all  fatty  matters  have  been  extracted,  is  a  decidedly  more  ele- 
gant, but  also  more  expensive  article,  which  possesses  only  the  other  ad- 
vantage of  absorbing  fluids  more  readily,  whence  its  trade-name  "  absorb- 
ent cotton."  It  is  used  in  ordinary  practice,  chiefly  for  intra-uterine 
applications,  being  wrapped  on  a  stick  or  applicator.  I  always  employ  it 
to  tampon  the  cervix  or  uterine  cavity,  and  occasionally  as  a  vaginal  tam- 
pon when  I  wish  thorough  saturation  of  the  cotton  by  the  medicated  fluid, 
as  in  the  application  of  strong  caustic  solutions  (chloride  of  zinc)  to  the 
cervix  and  vagina  in  carcinoma,  or  when  the  absorption  of  discharges  is 
intended.  I  therefore  always  keep  both  the  ordinary  and  the  absorbent 
cotton  in  my  drawer,  ready  for  instant  use.  For  the  removal  of  fluids  and 
secretions  from  the  cer^dx  with  the  cotton-wraj^ped  stick  or  forceps,  the  ab- 
sorbent cotton  excels  the  ordinary  variety. 

The  manner  of  using  medicinal  agents  in  powder,  solution,  or  ointment 
on  tampons,  has  already  been  described  in  the  preceding  chapter.  I  need 
merely  repeat  here  that  the  powders  are  sprinkled  on  the  dry  tamjoon,  or 
better,  the  tampon  soaked  in  Avater  or  glycerine,  or  covered  with  vaseline, 
is  rolled  in  the  powder ;  that  solutions  are  applied  by  saturating  tampons 
in  them  and  expressing  the  latter  more  or  less  before  introduction,  or  the 
medicated  tampons  may  be  allowed  to  dry  and  be  used  in  that  state  (par- 


200  MINOR    GYNECOLOGICAL    MANIPULATIONS. 

ticulaiiy  advisable  for  disinfectant — carbolic,  thymol ;  stj^ptic — solution 
of  persulphate  of  iron  ;  and  alterative — iodine,  remedies)  ;  and  lastly,  that 
medicated  ointments  are  smeared  over  the  cotton  and  left  in  situ  until  ab- 
sorption has  taken  place.  The  mere  emolhent  effect  of  vaseline  is  proba- 
bly made  use  of  more  frequently  in  this  manner  than  that  of  medicated 
ointments. 

It  is  always  advisable  to  keep  on  hand  a  supply  of  absorbent  cotton 
which  has  been  soaked  in  one  of  the  following  solutions  and  allowed  to 
dry :  Liq.  ferri  subsulph.,  1  part  to  3  of  water ;  alum,  1  part  in  12  of  hot 
water  ;  tincture  of  iodine,  pure ;  iodized  phenol,  pure  ;  carbolic  acid  or 
thymol,  1  part  to  30  or  50  of  water.  This  dried  medicated  cotton  can  be 
used  in  the  quantity  desu'ed  after  any  length  of  time  ;  the  iron  and  alum 
as  styptics,  chiefly  for  packing  the  cervical  and  uterine  canal  after  discis- 
sion and  removal  of  fibroids,  and  in  cancer  of  the  cervix ;  the  iodine  as  a 
disinfectant  after  operations  on  the  uterine  cavity,  and  as  an  alterative ; 
the  iodized  phenol  as  a  caustic  in  endotrachelitis  and  cervical  erosion  or 
cancer ;  the  disinfectants  as  supporters  of  the  above  tampons,  and  in  of- 
fensive discharges.  Care  should  be  taken  to  keep  the  iodized  cotton  in  a 
well-stoppered  bottle  in  a  dark  place. 

The  great  advantage  of  using  dried  ferrated  cotton  in  place  of  the 
freshly  soaked  article,  as  a  permanent  application  to  the  cervix  (as  in 
bleeding  cancer),  will  have  been  appreciated  by  all  who  have  seen  the 
liquid  iron  escape  from  the  cotton  and  run  down  the  vagina,  in  spite  of 
all  caution  and  previous  squeezing,  when  the  tampon  is  packed  tight. 
Besides,  the  operator's  hands  are  in  no  manner  improved  by  squeezing  out 
the  ii'on-soaked  cotton,  an  objection  by  no  means  to  be  overlooked  by  the 
gynecologist,  who  should  keep  his  fingers  not  only  clean,  but  sensitive. 
An  unpleasant  feature  of  all  medicated  cotton,  chiefly  the  ferrated,  is  that 
the  fibre  of  the  material  becomes  softened  and  more  or  less  destroyed  by 
being  soaked  and  boiled  in  the  medicated  solution,  and  that  tampons 
made  of  such  cotton  are  much  less  cohesive  and,  therefore,  less  serviceable 
than  when  made  of  raw  or  absorbent  cotton.  This  is  especially  noticeable 
when  it  is  desired  to  thrust  ferrated  cotton  rapidly  into  the  vagina  as  a 
tampon  for  hemorrhage,  and  the  forceps-points  slij)  through  the  loose 
fibres  as  through  tissue-paper.  Powders  may  also  be  applied  to  the  va- 
gina by  being  enclosed  in  small  bags  of  fine  muslin,  so-called  sachets, 
which  are  tied  at  the  mouth  with  a  string  long  enough  to  escape  from  the 
vagina,  and,  being  smeared  with  glycerine  or  vaseline,  are  introdiiced  by 
the  woman  herself  ;  or  a  piece  of  sheet-batting  may  be  used,  the  glazed 
surface  having  been  removed.  The  bag  soon  becomes  soaked  in  the  va- 
ginal discharge,  which  mingles  with  the  powder,  and  the  solution  thus 
formed  oozes  through  the  envelope.  Tannin,  alum  and  sugar  (alum  alone 
is  too  strong  to  be  applied  to  the  vagina  at  any  time),  zinc,  acetate  of  lead, 
may  be  applied  in  this  way,  which  certainly  is  a  better  method  than  any 
other  of  introducing  astringents  into  the  vagina  when  the  physician  is  not 
at  hand  to  do  it. 

A  favorite  remedy  with  some  practitioners  is  the  introduction  of  emol- 


TAMPONADE    OF    THE    VAGINA.  201 

lients  in  this  manner;  tlius,  ground  flaxseed,  slippery-elm  bark,  poppy- 
heads,  or  all  combined,  are  enclosed  in  a  fine  muslin  bag  of  the  size  of  a 
small  lemon,  soaked  in  hot  water,  and  then  pushed  by  the  patient  herself 
up  to  the  cervix.  This  is  best  done  on  retiring  at  night,  and  the  poultice 
is  removed  the  next  morning,  to  be  followed  by  a  hot  injection.  In  pelvic 
cellulitis,  chronic  ovaritis,  hyperplasia  uteri,  these  internal  poultices  cer- 
tainly act  beneficially  as  local  sedatives  and  alteratives. 

A  precaution  of  the  gTeatest  importance  in  applying  pledgets  of  cot- 
ton soaked  in  strong  caustic  or  diffusible  substances  to  the  cervix  or  va- 
gina, is  to  thoroughly  remove  all  excess  of  the  agent  by  careful  mojDping, 
and  then  to  apply  tampons  soaked  in  an  alkaline  fluid  to  neutralize  any 
possible  later  oozing  from  the  caustic  cotton.  It  is  almost  incredible  how, 
even  after  the  most  careful  expression  und  mopping,  more  or  less  of  the 
caustic  fluid  will  ooze  along  the  side  of  the  protecting  cotton  after  the 
patient  has  been  put  to  bed,  and  the  operator  will  find  the  evidence  of  it 
on  removiug  the  tampons  next  day.  By  neutralizing  this  possible  flow, 
as  above  indicated,  a  perhaps  very  annoying  slough  will  be  prevented. 
The  chloride  of  zinc  is  the  agent  particularly  in  my  mind  while  advising 
this  precaution,  and  the  bicarbonate  of  soda  in  saturated  solution  is  the 


Fig.  93. — TJterine  Dressing-forceps.    A  catch  near  the  handle  increases  the  utility  of  the  forceps. 


best  antidote.  Nitric  acid,  chromic  acid,  bromine,  can  also  be  neutralized 
by  this  same  agent.  For  nitric  acid,  I  generally  use  oil  or  vaseline  on  the 
tampons. 

I  have  already  spoken  in  the  preceding  chapter  of  the  manner  of  intro- 
ducing tampons  into  the  vagina.  I  there  referred  only  to  tampons  soaked 
in  glycerine,  the  necessity  for  the  daily  systematic  use  of  which  renders  it 
desirable  that  some  means  should  be  devised  which  will  enable  the  pa- 
tient to  introduce  them  efficiently  herself.  Ordinarily,  medicated  tam- 
pons require  to  be  placed  by  the  physician  himself,  through  one  of  the 
various  kinds  of  speculum,  because  the  size  of  the  tampon  or  the  nature 
or  strength  of  the  substance  with  which  it  is  covered  or  impregnated  pre- 
vent the  patient  fi-om  passing  it  through  the  vaginal  orifice  b}'  the  fingers 
only.  Small  pledgets  soaked  in  glycerine  are  usually  slipped  into  the 
vagina  without  difficulty  if  the  patient  possesses  an  ordinary  amount  of 
dexterity  or  boldness,  but  larger  tampons  are  introducible  by  the  fingers  only 
when  the  vaginal  orifice  is  exceedingly  patulous,  as  with  lacerated  perineum 
and  in  procidentia  vaginse  or  uteri.     I  shall  refer  to  these  cases  hereafter. 

To  enable  patients,  therefore,  to  introduce  glycerated  or  othei-wise 
medicated  tampons  themselves,  tubes  with  piston-rods  have  been  devised 
by  Thomas,  Barnes,  and  others,  into  which  the  tampon  is  placed,  and,  the 
tube  having  been  introduced  into  the  vagina,  pushed  out  with  the  piston. 


202 


MIl^OR    GYNECOLOGICAL    MANIPULATIONS. 


If  the  cotton  pledget  is  very  small,  not  larger  than  an  Englisli  walnut, 
these  porte-tamiDOUs  will  answer  very  well,  although  the  majority  of  un- 
married women  find  more  or  less  difficulty  (arising  from  awkwardness  or 
timidity,  as  much  as  from  naiTowuess  of  the  hymeneal  opening)  in  insert- 
ing the  tube.  But  when  it  is  desired  to  apply  larger  tampons  as  support- 
ers of  the  uterus,  dilators  of  the  vagina  or  carriers  of  a  larger  amount  of 
medicinal  substance,  these  slender  tampon-tubes  will  be  found  insufficient, 
and  the  aid  of  the  physician  wiU  be  needed  to  apply  the  tampon.  The 
same  holds  good  when  the  tampon  is  to  be  placed  in  a  certain  portion 
of  the  vagina,  as  before  or  behind  the  uterus  in  the  respective  displace- 
ments, a  maneuvre  which  can  be  properly  carried  out  only 
through  the  Sims  speculum.  The  extent  of  the  usefulness 
of  porte-tampons  is,  therefore,  the  introduction  of  small, 
soft  pledgets  soaked  in  glycerine,  giycerole  of  tannin,  or 
some  similar  solution,  or  covered  with  vaseline,  medicated 
or  not.  The  small  size  of  these  tampons  and  their  limited 
capacity  render  their  benefit,  with  the  exception  of  the 
giycerated,  comparatively  slight. 

Of  the  various  tubes,  the  hollow  glove-stretcher  of 
Barnes  (Fig.  94)  appears  to  me  the  most  useful,  as  it  is 
more  easily  introduced  and  admits  a  larger  tampon  than 
the  others. 

In  chronic  leucorrhea,  areolar  h}^Derplasia,  and  chronic 
cellulitis,  the  daily  introduction  through  a  tube  of  even 
these  small  tampons  soaked  respectively  in  some  astrin- 
gent giycerole,  pure  glycerine  or  iodized  glycerine,  will, 
for  the  want  of  a  more  thorough  application,  eventually 
result  in  benefit. 

The  insertion  of  a  tampon  of  ordinary  size  through  a 
tubular  or  bivalve  speculum  is  performed  in  the  following 
manner  :  the  tamj)on,  having  been  soaked  in  the  fluid  and 
expressed  so  as  not  to  drip,  or  covered  with  the  ointment, 
or  rolled  in  the  powder,  is  seized  with  the  uterine  dress- 
ing-forceps and  introduced  lengthwise  into  the  speculum, 
care  being  taken  in  doing  so  not  to  rub  off  the  powder  or 
ointment  with  which  it  may  be  covered,  or  to  cause  the  fluid  with  which 
it  is  impregnated  to  ooze  over  the  edge  of  the  speculum  and  drop  on  the 
clothes.  The  tampon  is  then  pushed  gently  forward  with  the  forceps,  the 
blades  of  which  still  enclose  it,  until  it  reaches  the  cervix  (which,  of  course, 
must  have  been  exposed  before).  The  cord  of  the  tampon  has  been  al- 
lowed to  hang  out  of  the  speculum.  The  forceps  now  release  the  tampon, 
and  the  point  of  the  closed  blades  crowds  the  cotton  well  up  against  the 
cervix,  if  that  be  the  pui-pose  ;  if,  however,  the  tampon  is  to  remain  length- 
wise in  the  vagina,  as  when  it  is  used  to  separate  the  walls  or  bring  all  of 
its  surface  in  contact  with  them,  this  packing  is  omitted,  and  the  tampon 
merely  held  firmly  with  the  point  of  the  closed  forceps,  while  the  left 
hand,  which  all  this  time  has  been  supporting  the  speculum,  withdraws 


Fig.  04. — Barnes' 
Glove-stretcher  Tam- 
pon Tube. 


!  TAMPONADE    OF    THE    VAGINA.  203 

that  instrument.     The  tampon  must  be  pushed  up  with  sufficient  firmness 
to  prevent  its  being  dislodged  or  removed  when  the  speculum  is  with- 
drawn ;  but  care  should  be  taken  not  to  allow  the  forceps-point  to  slip  be- 
side the  cotton  when  this  pressure  is  made,  and  injure  the  vaginal  vault, 
as  I  have  seen  hapjpen  several  times.     This  could,  of  course,  be  always 
avoided  by  jDressing  the  tampon  up  between  the  forceps-blades,  instead  of 
with  the  closed  blades  ;  but  I  have  advised  the  latter  because  I  have  expe- 
rienced difficulty  in  removing  the  open  blades  from  each  side  of  the  tam- 
pon  when  it  has  been  tightly  packed  and  the  speculum  has  been  removed. 
The  best  way,  perhaps,  is  to  open  the  blades  slightly,  and  push  with  both 
blades  separated  about  half  an  inch,  when  they  will  not  be  likely  to  slip. 
Any  stick,  like  a  stout  whalebone  applicator  or  a  penholder,  may  be  used 
'  to  push  up,  pack,  and  hold  the  tampon.     But  I  have  advised  the  long 
dressing-forceps  because  they  are  (or  should  be)  alwaj-s  at  hand,  because 
the  tampon  is  seized  with  them,  and  they  answer  every  purpose.     They 
;  are  an  invaluable  instrument  in  uterine  practice.     I  always  employ  them 
i  as  the  carrier  of  cotton  with  which  I  wij)e  off  the  cervix  or  remove  an  ex- 
I  cess  of  some  fluid  application,   and  find  them  far  more  convenient  than 
sponge-holders  or  cotton-wrapped  whalebone  sticks  for  this  purpose.     The 
;  latter  have  to  be  wrapped  afresh  for  each  mopping,  while  with  the  forceps 
I  a  bit  of  cotton  is  simply  torn  from  the  roll,  and  thrown  into  the  slop-jar 
■  when  soiled.     For  applications  of  fluid  agents  to  the  cervix  and  vagina, 
however,  the  cotton-wrapjDed  applicator  is  more  convenient. 

In  introducing  a  medicated  tampon  through  a  Sims  speculum,  care 

I  should  be  observed,  when   passing   it  into  the  vagina  with  the  forceps, 

i  not  to  touch  the  edge  of  the  orifice    and    strip  off  the  agent,  which,  if 

'  fluid,  will  flow  over  the  lower  natis  on  the  patient's  clothes,  and  in  any 

case  may  cause  smarting  of  the  sensitive  vulva.     When  the  tampon  has 

!  been  passed  up  into  the  vaginal  pouch  and  properly  adjusted  it  is  held 

'  between  the  blades  of  the  forceps  (which  in  this  position  and  with  Sims' 

speculum  can  easily  be  removed)  and  the  speculum  withdrawn  with  the 

:  tip  of  its  vaginal  blade  pointing  backward  until  it  emerges  from  the  va- 

,  gina.     If  care  is  not  taken  to  keep  the  blade  directed  well  backward  in 

\  withdrawing  it,  but  the  point  is  allowed  to  leave  the  posterior  wall  dur- 

;  ing  this  maneuvre,  the  tamjDon  may  very  readily  be  caught  in  the  groove 

(  of    the   blade  and    dislodged   from    the    fornix,  or    entirely   removed — 

i  scooped,  as  it  were,  out  of  the  vagina.     When  the   speculum    has  been 

withdrawn,  the  dressing-forceps  are  also  removed ;  indeed,  their  pressure 

against  the  tampon  may  be  relaxed  as  soon  as  the  point  of  the  speculum 

has  passed  that  object. 

After  removing  the  speculum,  the  external  parts  should  be  cleansed 
of  any  secretions  or  fluids  which  may  have  escaped  from  the  vagina 
or  tampon,  and  the  cord  so  adjusted  that  the  patient  can  easily  find  it 
when  she  wishes  to  remove  the  tampon.  If  there  should  be  any  oozing 
of  medicated  fluid  from  the  vagina,  or  any  danger  of  tbis  occurring,  it 
is  well  to  tuck  a  piece  of  cotton  loosely  into  the  vulvar  cleft,  pressing 
it  lengthwise  between  the  labia,  so  as  to  give  it  a  certain  amount  of  ad- 


204  MINOR    GYNECOLOGICAL    MANIPULATIONS. 

herence.  The  patient  should  be  told  to  remove  this  when  she  wishes  to 
empty  her  bladder. 

I  have  already  stated  that  tampons,  even  when  disinfected,  should 
rarely  be  allowed  to  remain  longer  than  twenty-four  hours.  It  is  custom- 
ary" to  tell  patients  to  remove  a  tampon  which  has  been  introduced  about 
noon  of  one  day  on  the  morning  of  the  next — that  is,  after  about  eighteen 
hours.  All  the  benefit  to  be  derived  from  that  tampon  and  its  ingredients 
has  been  obtained  by  that  time.  An  exception  is  made  only  when  a  very 
large  astringent  tampon  has  been  introduced  as  a  substitute  for  a  pessary 
in  vagino-uterine  prolapse,  and  it  is  to  be  replaced  at  once  by  a  fresh  tam- 
pon, which  it  is  not  convenient  to  do  oftener  than  every  other  day,  and  in 
some  cases  of  hemorrhage,  when  a.  too  eaiiy  removal  might  again  start  the 
bleeding.     These  exceptions  will  be  referred  to  hereafter. 

The  manner  of  removing  the  tampon  by  the  attached  cord  has  also  been 
described,  and  the  precautious  to  be  used.  Ordinary  medicated  tampons, 
whether  introduced  by  the  physician  through  a  speculum  or  by  the  patient, 
are  generally  supplied  with  a  cord  for  removal  by  the  patient ;  only  such 
tampons  as  are  designed  for  purposes  of  support  or  hemostasis,  being  ap- 
phed  in  a  particular  manner  and  perhaps  intended  to  be  replaced  at  once 
by  a  fresh  one,  are  not  furnished  with  a  string,  and  are  removed  by  the 
l^hysician  with  speculum  and  forceps. 

Should  an  accident  occur  and  the  cord  break  during  the  attempted 
removal  of  the  tampon,  it  is  best  to  introduce  a  Sims  speculum  at  once 
and  remove  the  cotton  with  forceps  ;  or,  as  ah'eady  stated,  in  the  ab- 
sence of  such  a  speculum,  the  two  fingers  of  the  left  hand  or  the  handle 
of  a  large  spoon  properly  bent,  may  take  its  place  as  a  perineal  re- 
tractor and  expose  the  vagina  sufiiciently  to  enable  the  forceps  or  fin- 
gers of  the  other  hand  to  seize  and  remove  the  cotton.  A  tampon  may 
be  removed  also  through  a  bivalve  expanded  to  its  greatest  width,  but  this 
is  difficult  through  a  tubular  speculum,  the  point  of  which  pushes  the 
tampon  aside  or  crowds  it  into  the  cul-de-sac. 

A  cleansing  injection  of  tepid  or  hot  water,  with  or  without  subse- 
quent disinfectant  or  astringent  addition,  should  be  taken  immediately 
after  the  removal  of  a  tampon,  unless  counterindications  to  injections  ex- 
ist, such  as  tendency  to  hemorrhage.  Patients  should  be  told  that  after 
the  removal  of  an  astringent  tampon  they  may  experience  some  difficulty 
in  introducing  the  nozzle  of  the  syringe  to  the  usual  depth,  owing  to 
the  temporary  contraction  of  the  canal,  and  that  they  need  not  be 
alarmed  at  this.  They  should  also  be  cautioned,  if  there  is  an  erosion  or 
easily  bleeding  surface  of  any  kind  on  the  cervix,  against  introducing  the 
nozzle  of  the  syringe  to  its  full  length,  for  fear  of  striking  against  the 
eroded  spot  and  producing  fresh  hemorrhage. 

2.  ^s  a  Means  of  Retaining  Certain  Substances  Introduced  into  the  Ute- 
rus in  their  Proper  Position. — If  a  conical  tent  of  cotton  has  been  intro- 
duced into  the  cervical  canal  as  a  hemostatic  after  discission,  or  a  sponge, 
laminaria,  or  tupelo  tent  has  been  applied,  or  a  stem-pessary  has  been  in- 
serted into  the  uterus,  some  support  may  be  required  to  pi-eveut  these 


TAMPONADE    OF    THE    VAGINA.  205 

various  bodies  from  becoming  displaced  and  slijDping  out  of  the  uterus. 
Sucli  support  is  not  always  needed,  for  the  cotton  tent  may  be  so  tightly 
packed  as  not  to  slip,  or  the  dilating  tents  may  dilate  so  rapidly  (chieHy 
the  sponge)  as  to  retain  themselves  ;  or  the  stem-pessary  may  be  kept  in 
place  by  its  bulb  pressing  against  the  vaginal  wall,  as  is  always  the  case 
in  ante-displacement  of  the  uterus.  But  as  regards  the  cotton  and  the 
tents  it  is  always  safer  to  make  sure  of  their  being  retained  by  placing 
flat  pledgets  of  cotton  over  the  cervix,  and  then  supporting  this  flat 
tampon  by  a  cylindrical  one.  These  tampons  can  be  applied  through  a 
large  cylindrical  or  bivalve  speculum,  which  properly  exposes  the  cervix  ; 
but,  as  the  object  they  are  to  support  will  most  probably  have  been  in- 
troduced through  a  Sims  (at  least  it  is  most  easily  so  introduced)  the 
tampons  will  naturally  be  applied  at  once  through  that  speculum. 
Neither  tampon  need  have  a  cord  attached,  since  in  the  case  of  the  cotton 
tent  the  operator  would,  after  a  discission  of  the  cervix,  naturally  remove 
the  pledget  himself  through  a  speculum  within  twenty-four  hours,  and 
replace  it  by  fresh  wadding,  and  the  dilating  tent  should  also  always  be 
removed  by  the  jDhysician  through  a  speculum.  In  some  cases,  however, 
■where  I  introduce  a  medicated  cotton  tent  into  the  uterus  (as  hereafter  to 
be  described),  I  place  a  cylindrical  tampon  against  the  cervix  and  direct 
the  patient  to  remove  it  next  day  and  use  her  hot  injection,  the  uterine 
tent  coming  away  spontaneously  in  several  days.  Or  I  attach  a  thread 
to  the  uterine  tent  and  tell  the  patient  to  remove  it  the  next  day  with  the 
vaginal  tampon.  The  tampons  should  be  soaked  iu  a  disinfectant  glyce- 
rine solution,  and  are  introduced  and  removed  precisely  as  already  de- 
scribed, care  being  merely  taken  to  have  the  disk  tampon  over  the  cervix 
large  enough  to  insure  its  retaining  its  place  over  the  external  os. 

If  it  is  found  that  a  stem-pessary  is  not  retained,  and  a  solid  support 
by  means  of  an  attached  vaginal  j^essary  is  not  borne,  or  is  counter-indi- 
cated, the  daily  application  of  a  cotton  tampon  over  the  cervix,  as  just  de- 
scribed, will  answer  the  purpose.  Since  the  stem  would  slip  out  if  the 
tampon  were  removed  without  at  once  introducing  anothei*,  it  is  obvious 
that  only  the  physician  himself  should  introduce  and  remove  these  tam- 
pons, therefore  no  cords  are  needed.  The  application  of  a  cylindrical  or 
round  tampon  in  the  anterior  vaginal  pouch  may  serve  to  retain  the  stem 
by  pushing  the  cervix  against  the  posterior  wall. 

3.  As  a  Ifeans  of  Retaining  the  Uterus  in  its  Normal  or  some  other  Po- 
sition, and  of  Supijorting  a  Replaced  Prolapsed  Ovary. — There  are  numer- 
ous instances  in  which  it  is  desirable  to  steady  and  support  the  normally 
situated  healthy  uterus  immovably  in  its  position,  and  where  a  hard  pes- 
sary is  not  borne.  As  examples  of  such  cases  may  be  cited  inflammatory 
and  spasmodic  conditions  of  the  bladder  or  rectum,  acute  ovaritis,  in  which 
affections  the  constantly  varying  pressure  of  a  normally  movable  uterus 
on  the  inflamed  organs  will  cause  pain  ;  or,  in  displacements  of  the  ute- 
rus, ante,  retro,  or  downward,  a  hyperemic  and  tender  uterine  body,  or 
edematous  or  inflamed  parametrium  will  not  tolerate  the  steady  pressure 
of  a  hard  supporter.     Or  an  inflamed  and  exquisitely  tender  prolapsed 


206  MI^OR    GYiS-ECOLOGICAL    MANIPULATIONS. 

ovary  forbids  tlie  use  of  sucli  a  pessary,  and  still  a  support  of  that  ovary 
is  called  for.  In  such  cases  the  substitution  of  the  permanent  suj)port 
by  the  daily  introduction  of  glycerated  cotton  tampons  will,  in  many  cases, 
gradually  accustom  the  parts  to  the  pressure,  make  room  for  a  permanent 
pessary,  and  relieve  both  inflammation  and  displacement. 

Such  a  tampon,  or  such  tampons,  to  be  efficient  must  be  placed  and  re- 
tained j)recisely  where  the  pressure  is  most  needed.  It  is,  therefore,  in- 
dispensable that  they  be  introduced  through  the  Sims  speculum,  which  ex- 
poses the  whole  vaginal  vault  and  permits  free  motion  of  the  uterus.  The 
method  may  be  described  in  a  few  words.  The  uterus  or  ovary  having 
been  manually  replaced,  if  a  displacement  existed,  the  cervix  is  exposed 
by  the  Sims  and  seized  by  its  anterior  lip  with  a  tenaculum  and  drawn 
gently  in  the  direction  opposite  to  the  spot  where  the  first  tampon  is  to 
be  applied.  The  posterior  cul-de-sac  being  the  deepest,  is  generally  first 
filled  ;  the  cervix  is,  therefore,  drawn  anteriorly,  and  a  round,  not  too  hard, 
cotton  tampon  soaked  in  glycerine  is  seized  with  the  dressing-forceps  and 
placed  behind  the  cervix,  where  it  is  gently  packed  tight  with  the  forceps. 
The  tenaculum  then  being  removed,  a  similar  tampon  is  placed  in  front  of 
the  cervix  and  also  packed  as  tight  as  the  much  more  shallow  anterior 
pouch  permits.  A  tolerably  large  flat  disk  tampon  is  then  placed  directly 
over  the  cervix  and  the  first  two  tampons,  and  this  dislc  again  supported 
by  another  flat,  or  a  cylindrical  tampon  placed  lengthwise  parallel  with  the 
long  axis  of  the  vagina.  It  may  not  be  absolutely  necessary  to  apply  this 
last  tampon  if  the  patient  is  to  remain  in  the  recumbent  position  while  re- 
taining the  tampons,  but  if  she  is  allowed  to  walk  about,  the  upper  pledg- 
ets will  surely  be  displaced  unless  supported  by  the  cylinder.  If  the  vagi- 
nal pouch  is  very  large  and  wide,  or  if  it  is  desired  to  make  transverse  as 
well  as  posterior  and  upward  pressure  (as  in  ovarian  prolapse)  a  cylindri- 
cal tampon  applied  transversely  may  be  preferable  to  the  ball.  If  entire 
immobility  of  the  uterus  is  desired,  a  cylindrical  tampon,  applied  trans- 
versely in  each  of  the  four  sections  (posterior,  anterior,  and  two  lateral) 
of  the  vaginal  pouch,  and  secured  by  a  fairly  large  disk  and  a  longitudinal 
cylinder,  will  attain  the  object.  These  tampons  must  be  renewed  every 
day  ;  and  it  is  a  good  plan  to  have  the  patient  remove  them  by  the  attached 
cords  (which  may  be  marked  or  of  different  lengths,  as  described  above, 
although,  as  a  rule,  little  difficulty  will  be  experienced  in  removing  the 
whole  mass  at  once  in  these  cases),  and  take  a  hot  vaginal  bath,  before  the 
physician  comes  to  reapply  them.  If  the  patient  goes  to  the  physician's 
office  it  is  certainly  better  that  she  should  retain  the  tampons  until  they 
can  be  at  once  replaced  by  fresh  ones,  and  cords  are  then  not  required. 
A  daily  hot  injection,  however,  materially  aids  the  treatment  in  these 
affections. 

These  tampons  are  most  useful  in  retrodisplacement  of  the  uterus,  with 
or  without  ovarian  prolapse,  in  which  cases  the  uterine  body  or  retro- 
uterine cellular  tissue  is  frequently  too  tender  at  the  outset  of  the  treat- 
ment to  tolerate  a  hard  supporter.  If  continued  with  sufficient  per- 
severance, the  displacement  may  even  be  cured  by  these  soft  tampons,  and 


TAMPOISTADE    OF    THE    VAGINA. 


'207 


Fig.  95.— Uterus  Supported  by 
Tampons,  either  as  Applied  after 
Replacement  of  a  Hetroverted  Ute- 
rus, or  a  Prolapsed  Ovary,  or  for 
Anteversion  and  Sagging  (P.  F.  M.). 


a  subsequent  hard  pessary  rendered  unnecessary.  Wlien  the  retrodisplaced 
fundus  uteri  is  adherent,  these  daily  emollient  and  hydragogue  tampons 
may  in  time,  by  their  combined  pressure  and  alterative  action,  bring  about 
the  absorption,  or  at  least  stretching,  of  the  adhesions,  and  permit  a  re- 
placement of  the  organ.  If  there  is  conges- 
tion of  a  prolapsed  ovary,  or  the  retro-uterine 
parts  •  are  very  relaxed  and  tender,  the  substi- 
tution of  a  watery  solution  of  tannin  (1 :  4)  for 
the  glycerine  in  the  tampon  is  recommended 
by  Dr.  Fordyce  Barker. 

The  painting  of  the  vaginal  mucous  sur- 
face over  the  inflamed  parts  with  tincture  of 
iodine  before  apj^tying  the  supporting  tampons 
is  a  good  plan,  but  it  must  not  be  done  oftener 
than  once  a  week,  and  only  the  simple  tincture 
be  used,  or  the  iodine  and  pressure  combined 
will  exfoliate  the  epidermis. 

Besides  in  retrodisplacements,  I  have  found 
these  daily  tampons  of  great  benefit  in  another 
variety  of  uterine  deviation,  where  a  heavy  subinvoluted  uterus  anteverts 
and  sinks  down  in  the  pelvis  so  that  its  hard  cervix  rests  on  the  posterior 
vaginal  wall,  into  which,  as  the  patients  express  it,  it  seems  to  bore.  The 
patients  complain  of  a  steady,  gnawing,  burning  pain  in  the  lower  portion 
of  the  sacrum,  which  is  at  once  relieved  by  lifting  the  cervix  away  from  the 
posterior  vaginal  wall  and  supporting  it.     In  old  cases  of  this  displacement 

hard  pessaries  are  often  not 
borne  at  first,  and  the  daily  gly- 
cerated  cotton  tampon  answers 
admirably.  I  have  entirely  cured 
a  lady  of  both  her  displacement 
and  hyperplasia,  as  well  as  of  a 
chronic  ovaritis  of  the  left  side 
(for  which,  it  is  true,  constant 
abdominal  counter-irritation  was 
also  employed),  by  packing  the 
posterior  cul-de-sac  with  glyce- 
rated  cotton  every  day  before  she 
left  her  bed,  for  a  period  of  three 
months.  She  could  wear  no  j)es- 
sary,  and  could  scarcely  walk 
without  the  cotton  support ;  with 
it  she  was  perfectly  comfortable. 
She  is  now,  four  years  later,  a 
perfectly  well  woman. 
Such  tampons  are  easily  applied  by  the  physician  alone,  in  the  absence 
of  a  nurse,  by  inserting  the  Sims  speculum  in  the  knee-breast  position. 
The  left  hand  holds  the  speculum  and  retracts  the  perineum,  thus  admit- 


PlG.  96. — Downward  Safreinsr  of  Anteverted  Uterua 
(P.  F.  M.).  Compare  with  Fig.  16,  representing  simple 
Anteversion. 


208  MINOE    GYNECOLOGICAL    MAISTIPULATIOI^J-S. 

ting  air,  and  dilating  and  fully  exjDOsing  the  vaginal  canal  with  the  cervix ; 
the  right  hand  places  the  cotton  with  the  dressing-forceps  where  it  is 
wanted,  and  the  patient  lies  on  her  left  side  for  a  few  moments  before  ris- 
ing in  order  to  permit  the  air  to  escape  and  the  "vagina  to  contract  about 
and  fix  the  tampons.  I  have  taught  private  nurses  to  apj^ly  the  cotton  in 
this  way,  and  have  thus  saved  patients  living  out  of  town  the  trouble  of 
coming  to  me  and  the  expense  of  having  me  go  to  them.  One  precaution 
is  to  be  mentioned  in  applying  tampons  in  this  manner,  viz.,  that  the  com- 
plete distention  of  the  vagina  by  air  requires  rather  larger  and  more  tam- 
pons in  order  to  insure  their  proper  retention  than  is  necessary  in  the 
lateral  decubitus. 

I  have  thus  far  spoken  of  tampons  only  for  the  retention  of  ante-  and 
retrodisplaced  uteri.  In  lateral  displacements  the  tampons  are  placed  on 
either  side  of  the  cervix,  the  one  to  crowd  the  cervix  away  from  the  side 
toward  which  it  is  directed  and  bring  it  in  the  median  line,  the  other  to 
push  up  the  fundus.  The  usual  disk  and  cylinder  are  required.  The  utility 
of  these  lateral  tampons  is  not  as  great  as  that  of  the  posterior,  owing  to 
the  shallowness  of  the  lateral  vaginal  pouches.  Still,  in  view  of  the  diffi- 
culty of  procuring  efficient  and  supportable  hard  pessaries  for  these  latero- 
displacements  (which,  unless  congenital,  are  usually  due  to  traction  by 
cellulitic  or  peritonitic  adhesions)  the  cotton  supjDorts  may  be  found  ser- 
viceable in  the  comparatively  rare  cases  of  positive  disturbance  by  this 
displacement. 

It  now  remains  for  me  to  speak  of  the  use  of  cotton  tampons  as  veri- 
table supports,  as  a  substitute  for  jDessaries  and  vagino-abdominal  sup- 
porters, in  cases  of  partial  and  complete  prolapsus  uteri  et  vaginae.  While 
in  the  ante-,  retro-,  and  lateral  displacements  the  tampons  are  small  and 
correct  the  displacement  more  on  the  principle  of  the  lever  pessary,  in  j)ro- 
lapses  of  the  vagina  and  uterus  they  act  entirely  by  their  size  and  have  a 
mere  retaining  power.  The  bulk  of  the  tampon,  in  fact,  secui*es  its  reten- 
tion ;  a  small  tampon  would  be  of  no  use  whatever,  as  it  would  be  forced 
out  on  the  first  expulsive  motion.  These  large  tampons  need  therefore 
only  to  be  pushed  into  the  vagina  as  far  up  as  they  can  be  crowded,  and 
usually  require  to  be  guarded  against  expulsion  by  intra-abdominal  jDress- 
ure  by  a  broad  T-bandage.  The  tamioou  in  these  relaxed  conditions  of 
the  vagina  and  uterine  supports  merely  takes  the  place  of  a  pessary,  the 
majority  of  which  instruments  are  either  too  small  or  too  weak  to  retain 
the  uterus  during  the  forcible  expulsive  efforts  made  in  walking,  lifting 
{which  the  women  suffering  from  these  affections  are  generally  obliged  by 
poverty  to  do),  and  defecation  ;  or  too  large,  and  give  pain  or  cause  ex- 
coriation and  ulceration  of  the  vagina.  But  these  cotton  pessaries  possess 
two  great  advantages  for  the  treatment  of  prolapsus  vaginse  et  uteri  over 
permanent  mechanical  supporters,  and  these  are  :  1,  their  cheapness,  and 
2,  the  possibility  of  impregnating  them  with  astringent  substances  which 
contract  the  vaginal  walls  and  ultimately  (except  in  senile  atrophy),  restore 
their  tonicity  to  a  greater  or  lesser  extent,  and  fit  them  for  a  permanent 
supporter.     Such  an  astringent  is  pre-eminently  the  finely  ]Dowdered  tan- 


TAMPONADE    Or    THE    VAGINA.  200 

nin,  so  frequently  spoken  of  in  these  pages.  Such  tampons  may  have  to 
be  renewed  daily  for  months,  at  least ;  but  they  will  not  fail  to  secure  de- 
cided improvement  in  moderately  new,  and  certainly  temporary  relief  (so 
long  as  used)  in  old  cases.  I  have  met  with  many  cases  of  total  proci- 
dentia in  which  none  of  the  complicated  and  expensive  contrivances  sup- 
plied by  the  instrument-makers  retained  the  organ  properly,  or  at  least 
painlessly  and  without  injury,  but  I  have  still  to  see  the  case  in  which  the 
large  tannated  cotton  tampon  supported  by  a  T-bandage  failed  to  achieve 
this  result  without  injury  or  pain.  An  objection  to  it  certainly  is  that,  to 
be  properly  apjolied  and  to  do  the  most  good,  it  must  be  introduced  through 
a  speculum  and  tightly  packed  by  a  physician.  But  this  objection  will 
really  hold  good  only  in  localities  where  the  patient  has  no  dispensaries 
to  visit  every  day  or  two  ;  in  cities,  no  poor  patient  has  this  excuse,  cer- 
tainly not  in  this  country  ;  and  the  wealthy  can  secure  the  physician's  at- 
tendance as  often  as  they  are  ready  to  remunerate  him.  And,  even  for 
the  poor  who  have  no  charitable  institutions  at  their  command,  as  in  coun- 
try districts,  this  method  is  available,  because  they  can,  after  a  fashion, 
apply  the  tampons  themselves,  as  I  shall  presently  show. 

I  have  ah-eady  stated  that  the  large  tampon  is  best  inserted,  in  these 
cases,  through  a  speculum,  which  may  be  the  largest  size'  of  cylindrical  or 
a  bi-  or  trivalve,  but  is  alwa^^s  preferably  the  Sims.  If  a  tubular  or 
plurivalve  speculum  is  used,  the  tampon  must  be  crowded  in  sidewise,  so 
as  not  to  become  blocked  at  the  mouth  ;  if  the  Sims  is  employed,  the  lar- 
gest-sized tampon  may  be  easily  laid  exactly  where  it  is  wanted. 

These  medicated  astringent  tamjDons  are  especially  useful  and  curative 
in  subinvolution  and  joi'olapse  of  the  anterior  or  posterior  vaginal  wall, 
so-called  cystocele  or  rectocele,  in  which  the  astringent  is  vastly  more 
effectual  in  restoring  the  natural  tonicity  of  the  parts  than  in  old  pro- 
lapsus uteri.  Pessaries,  even  the  latest  and  most  efficient,  that  of  Gehrung, 
do  not  act  as  curative  means  ;  they  are  merely  retentive  agents.  That 
portion  of  the  tampon  which  is  to  be  j^laced  in  contact  with  the  subin- 
voluted  or  prolapsed  part  is  most  heavily  saturated  with  the  astringent, 
which  may  even  be  pow^lered  on  that  spot,  and  the  tampon  is,  therefore, 
best  placed  through  the  Sims,  whereby  most  perfect  adaptation  is  secured 
and  none  of  the  ingredients  are  expressed  or  wiped  off.  I  have  had  such 
good  success  with  these  tampons,  in  rectocele  particularly,  as  to  look  upon 
them  as  curative  when  the  prolapse  is  complicated  with  fresh  subinvolu- 
tion of  the  vaginal  wall.  In  one  case  of  aggravated  rectocele,  within  six 
months  after  confinement,  I  relieved  the  urgent  distress  by  tannated  tam- 
pons daily  applied,  telling  the  lady  that  it  wovdd  be  necessary  for  her  com- 
plete cure  to  operate  on  and  sew  up  the  perineum,  which  was  lacerated  to 
the  sphincter  during  her  first  labor  fifteen  years  before.  As  the  hot 
weather  was  approaching  I  decided  to  defer  the  operation  till  the  fall, 
and  instructed  her  in  the  use  of  the  tampons  while  she  was  away  in  the 
country.  When  I  saw  her  again  in  the  autumn,  to  my  surprise  the  recto- 
cele had  entirely  disappeared,  and  to  this  day,  eight  years  later,  has  not 
reappeared.     The  tannin  tampons  thus  deprived  me  of  a  very  lucrative  and 


210  MINOR    GYNECOLOGICAL    MANIPULATIONS. 

probably  creditable  operation.  So  favorable  a  result  will  rarely,  however, 
be  met  with  in  cases  where  the  confinement  is  more  remote,  and  complete 
involution  of  the  vaginal  walls  has  taken  place. 

I  have  spoken  of  the  necessity  for  the  physician's  introducing  these 
tampons  as  an  objection.  There  can  be  no  question  that  they  do  vastly 
more  good  if  properly  packed  tight  by  the  physician  ;  but  in  inveterate 
cases  of  total  procidentia  even  the  incomjDlete  painless  retention  of  the 
prolajDsed  mass  is  regarded  as  a  boon,  and  the  means  by  which  this  can  be 
attained  are  joyfully  hailed  by  the  patient.  I  have  had  a  large  experience 
with  this  remedy  among  the  poor  classes,  and  have  always  found  that  the 
patient  herself,  if  she  be  possessed  of  the  ordinary  amount  of  intelhgence, 
can  readily  be  taught  to  introduce  the  tampon.  The  vaginal  orifice  is  gen- 
erally exceedingly  patulous,  by  reason  of  the  lacerated  perineum  and  pro- 
lapsed vaginal  walls,  and  a  tampon  of  considerable  size  (as  large  as  a 
duck's  or  even  a  goose's  egg)  can  be  pushed  into  the  canal  by  the  patient 
herself.  In  poor  patients  this  possibility  is  a  great  advantage,  not  to  be 
underestimated  in  those  frequent  cases  where  no  permanent  supporter 
can  be  borne.  I  show  the  women  the  size  and  shape  of  the  tampon — in- 
deed, generally  give  them  one  as  a  sample — tell  them  to  smear  its  surface 
completely  with  lard  or  dip  it  in  ohve  oil  or  glycerine,  and  then  roll  it  in 
the  astringent  powder,  generally  tannin,  which  they  will  get  by  prescrip- 
tion at  the  druggist's.  Then,  lying  on  the  back  with  thighs  flexed  and 
separated,  they  draw  apart  the  labia  with  the  fingers  of  one  hand  and 
steadily  crowd  the  tampon  into  the  vagina  with  the  other,  care  being 
taken  to  leave  the  string  by  which  it  is  to  be  withdrawn  protruding  from 
the  vulva.  Such  a  tampon  should  be  renewed  every  twenty-four  hours, 
the  vagina  first  being  cleansed  by  tepid  injections.  The  tough,  epider- 
moid mucosa  of  old  prolapsed  vaginae  bears  this  astringent  treatment  for 
months  without  becoming  excoriated  by  the  tannin  and  j^ressure  ;  if,  how- 
ever, the  epithehum  begins  to  show  signs  of  exfoliation,  or  if  the  vagina  is 
tender,  as  in  simple  rectocele  or  cystocele,  the  tampon  should  be  soaked 
in  a  solution  of  tannin  in  glycerine  1  :  4  or  6,  and  squeezed  nearly  dry  be- 
fore being  introduced.  When  well  crowded  into  place,  the  tampon  should 
always  be  retained  by  a  broad  T-bandage  covered  by  oiled-silk  where  it 
rests  against  the  vulva.  These  tampons  can  be  worn  for  months,  each 
daily  reapplication  being  preceded  by  a  cleansing  injection.  It  is  well  to 
omit  the  astringent  occasionally  and  apply  merely  a  giycerated  or  vaselined 
tampon,  in  order  to  avoid  producing  excoriation  of  the  vaginal  mucosa,  or 
to  alternate  day  by  day  with  the  astringent  and  emollient  tampon. 

4.  As  a  Mechanical  Support  and  Stimulus  to  the  Pelvic  Vessels,  and  as  an 
Alterative  to  the  Pelmc  Tissues  hy  Means  of  the  Direct  Pressure  it  Exerts  on 
them. — In  many  cases  the  vessels  of  the  jDelvic  organs,  chiefly  the  veins, 
are  in  a  state  of  chronic  passive  dilatation,  the  result  of  long-continued  ve- 
nous hyperemia.  This  hyperemia  may  be  due  to  obstriTctions  to  the  venous 
circulation  in  distant  organs  (as  in  congestion  of  liver  and  portal  circula- 
tion, or  cardiac  disease),  or  more  frequently  at  least,  in  the  class  of  cases 
met  with  by  the  gyuecologist,  to  subacute  and  chronic  inflammatory  con- 


TAMPONADE    OF    THE    VAGIISTA.  211 

ditions  of  the  pelvic  organs  (uterus,  ovaries,  and  cellular  tissue)  themselves. 
The  interruption  to  the  cii'culation  by  intrapelvic  exudations  of  lymph  and 
the  cicatricial  contractions  and  adhesions  resulting  therefrom,  is  also  a  not 
unfrequent  factor  in  this  passive  hyperemia.  In  such  cases  the  pelvic  tis- 
sues accessible  to  the  touch,  vulva,  vagina  (chiefly  the  upper  portions),  ute-_ 
rus  and  parametran  cellular  tissue,  impart  a  puffy,  doughy,  at  times  nodu- 
lar, sensation  to  the  examining  finger,  similar  to  that  afforded  by  edema  in 
external  parts.  The  vagina  is  generally  relaxed,  the  uterus  more  or  less 
displaced  and  enlarged,  the  ovaries  tender  and  swollen  ;  and  the  parame- 
trium, chiefly  laterally  and  behind,  exceedingly  sensitive  to  touch.  This 
last  is  particularly  the  case  when  there  has  been  some,  often  entirely  latent 
and  unsuspected,  pelvic  cellulitis,  or  where  there  is  a  chronic  inflammation 
of  the  numerous  lymphatic  vessels  and  occasional  glands  normally  found 
in  the  pelvic  cellular  tissue. 

Such  patients  complain  of  backache,  weight  and  fulness  in  the  pelvis, 
and  bearing  down.  They  are  generally  very  much  benefited  by  rest  in 
bed  and  hot-water  injections,  the  former  of  which  remedies  obviously  only 
the  better  classes  or  hospital  patients  can  sufiiciently  employ.  As  a  sub- 
stitute for  this  rest  and  as  a  support  to  the  distended  blood-vessels  the 
tamponade  of  the  vagina  has  been  successfully  employed.  I  first  saw  this 
method  systematically  described  in  print  by  Dr.  V.  H.  Taliaferro,  of  At- 
lanta, Ga.,  in  1878.  According  to  him,  the  solid  packing  of  the  vagina 
with  cotton  and  wool  is  an  excellent  remedy  in  subinvolution,  areolar  hy- 
perplasia, descensus  and  other  dislocations  of  the  uterus,  chronic  pelvic 
peritonitis  and  cellulitis,  adhesions  (and  I  would  add),  chronic  ovaritis — 
conditions  in  w^hich  painting  wdth  tincture  of  iodine,  hot  injections,  glyce- 
rine tampons,  etc.,  are  the  usual  remedial  means.  Dr.  TaUaferro  places  the 
patient  in  the  knee-breast  position,  which  is  preferable  to  the  lateral  semi- 
prone  position  as  a  suspender  of  intra-abdominal  pressure,  and  elevates 
the  perineum  with  Sims'  speculum.  Air  is  thus  admitted  into  the  vagina, 
which  is  expanded  like  a  balloon.  A  few,  two  or  three,  pledgets  of  cotton, 
soaked  in  glycerine  and  squeezed  dry,  are  then  packed  into  the  fornix  va- 
ginae with  long  dressing-forceps,  and  the  remainder  of  the  vagina  is  then 
filled  with  tightly  packed  loose  balls  of  dry,  finely  carded  sheep's  wool, 
down  to  the  floor  of  the  pelvis.  This  packing  should  be  done  gently  and 
carefully,  but  firmly,  and  the  tampon  should  not  reach  to  the  vulva,  or  it 
might  interfere  with  micturition  and  defecation,  and  give  pain  by  its  size. 
The  sheep's  wool  should  be  carbolized,  and  is  preferable  to  cotton  on  ac- 
count of  its  elasticity.  This  tampon  is  to  be  renewed  every  two  to  three 
days.  The  annoying  sacral  and  pelvic  pains,  and  the  feeling  of  dragging 
and  bearing  down,  almost  constantly  met  with  in  these  cases,  are  said  to 
disappear  almost  wholly  after  the  first  tamponade.  The  patients  are  not 
obliged  to  remain  in  bed,  unless  they  prefer  to  do  so.  Any  abrasions  pro- 
duced by  the  pressure  in  the  vagina  may  requu'e  the  interruption  of  the 
tampons  for  several  days,  or  the  wounds  may  be  covered  with  linen  strips 
smeared  with  vasehne.  The  tampons  should  in  any  case  be  applied  loosely 
at  first,  and  be  gradually  tightened.     According  to  TaUaferro  this  dilata- 


212  ]\II]SrOE    GYNECOLOGICAL    MANIPULATIONS. 

tion  does  not  relax  the  normal  vagina,  and  dilated  vaginae  are  incited  to 
contraction  by  it.  The  cases  reported  by  him  are  certainly  striking  ex- 
amples of  the  good  effects  of  this  treatment,  one  uterus  having  been  reduced 
from  three  and  a-half  to  two,  another  from  six  to  three  inches,  after  two  to 
four  mouths'  treatment.  In  one  case  an  annoying  gastric  hystero-neurosis, 
with  vomiting,  was  entirely  cured  by  the  local  j)ressure.  The  therapeuti- 
cal action  of  the  tamjDon  is  said  to  be  the  following  :  The  pressure  dimin- 
ishes, 1,  the  blood- supply  and  nutrition  ;  2,  it  increases  absorption  ;  3, 
it  destroys  hyperplastic  tissue  by  retrograde  metamorphosis ;  4,  it  dimin- 
ishes nerve-activity  ;  5,  it  rectifies  displacements.  The  following,  accord- 
ing to  Taliaferro,  are  the  advantages  of  this  method  :  1.  3Iore  rapid  effect. 
2.  The  patients  are  not  confined  to  their  beds  by  it  ;  on  the  contrary',  the 
•support  of  the  tampon  affords  them  relief  and  enables  them  to  walk  about, 
while  the  ordinary  measures  (caustics,  sponge-tents,  etc.,  necessitate  a 
more  or  less  prolonged  rest).  3.  The  entire  prevention  of  sexual  inter- 
course, a  therapeutic  auxiliary  but  seldom  observed.  4.  Absence  of  all 
inflammatory  irritation.  5.  Softening  and  dilatation  of  the  tissues,  while 
caustics  and  curettes  toughen  them.  6.  Absence  of  destruction  and  re- 
moval of  parts,  whereby  their  integral  condition  is  retained. 

I  have  thus  far  quoted  Taliaferro's  description  in  abstract,  but  am  able 
to  coincide  with  him  from  a  quite  extensive  experience  with  his  method. 
I  have  repeatedly  found  this  solid  column  of  cotton  (I  have  always  em- 
ployed cotton  only)  to  be  the  only  means  of  rehef  from  the  harassing 
backache  in  adhesion  of  a  hyperplastic  retroverted  uterus,  and  have,  after 
a  few  applications,  toughened  the  pai'ts  so  much  as  to  permit  the  pressure 
of  a  pessary  on  the  then  partly  replaced  fundus.  Of  the  value  of  this 
steady  elastic  pressure  and  supj^ort  in  reducing  the  size  of  an  engorged 
hj^jerplastic  or  (better  still)  subinvoluted  uterus,  and  restoring  the  normal 
circulation  to  the  edematous  and  congested  pelvic  cellular  tissue,  I  have 
no  doubt  whatever  ;  neither  of  the  potent  alterative  effect  of  this  pressure 
on  old  peritonitic  or  celluHtic  exudations  and  adhesions.  An  imj^erative 
condition  for  success  with  this  treatment  is  that  it  be  continued  for  a 
sufficient  length  of  time — for  months,  perhaps,  in  very  obstinate  cases,  for 
years.  I  have  to  add  to  Taliaferro's  description  merely,  that  it  vail  usually 
be  well  to  keep  patients  at  rest  for  twenty -four  hours  after  the  first  tam- 
pon, since  I  have  met  with  many  complaints  from  the  pressure  before  the 
vagina  has  become  accustomed  to  the  distention  and  the  sensitive  parts 
to  the  pressure.  One  other  condition  in  which  I  have  employed  the 
tampon  with  benefit,  is  a  certain  form  of  pachy- vaginitis,  where  the  vagi- 
nal walls  appeared  thickened,  edematous  j^erhaps,  and  the  surface  is  granu- 
lar and  rough  (gTanular  vaginitis).  The  j)ressure  here,  aided  by  the  as- 
tringent effect  of  an  aqueous  solution  of  tannin  in  which  the  tampons 
are  soaked,  seems  to  have  effected  a  cure  more  rapidly  than  the  applica- 
tions of  solution  of  nitrate  of  silver  and  astringents  ordinarily  employed. 
The  firm  tampons  cannot,  however,  be  continued  very  long,  as  the  vaginal 
surface  will  become  rapidly  abraded  after  a  few  applications,  and  the 
emollient  pledgets  must  be  substituted  for  the  solid  column. 


TAMPONADE    OF    THE    A^AGINA.  213 

If  the  vaginal  mucous  membrane  does  not  seem  to  bear  the  pressure 
of  moist  cotton  well,  the  tampons  may  be  inserted  perfectly  dry  and  there- 
by some  additional  pressure  be  obtained  through  the  extra  elasticity  of  the 
dry  material,  or  the  first  pledgets  may  be  covered  with  vaseline  as  an 
emollient. 

5.  As  a  Means  of  Dilating  or  Separating  the  Vaginal  Walls — a  Substitute 
for  a  Hard  or  Distensible  Dilator — in  Constriction  of  the  Vaginal  Canal  after 
Operation  for  Vaginal  Atresia  or  Stenosis,  in  Vaginismus  and  Spasm  of  the 
Levator  Ani  Muscle. — The  heading  expresses  the  indications,  and,  to  a  cer- 
tain extent,  the  method  for  the  application  of  cotton  pledgets  in  the  con- 
ditions there  enimierated.  "When  it  is  desired  to  separate  the  vaginal 
walls  after  an  operation  for  stenosis  or  atresia,  or  when  the  spasmodic 
contraction  of  the  levator  ani  and  perineal  muscles  prevents  sexual  inter- 
course, a  hard-rubber  or  glass  plug  is  generall}'  introduced  and  retained 
as  long  as  required.  In  the  absence  of  sucha  ]}\vig,  the  vaginal  walls  may 
be  separated,  and  the  spasmodic  muscular  contraction  overcome  by  dilat- 
ing the  canal  with  pledgets  of  cotton  smeared  with  vaseline  or  soaked  in 
glycerine,  and  packed  in  one  after  the  other  through  a  speculum,  which  is 
immaterial.  The  number  of  tampons  will  depend  upon  the  amount  of  dis- 
tention rec^uired  ;  they  will  not  be  retained  longer  than  twenty-four  houi'S, 

6.  As  a  Hemostatic,  by  its  Mechanical  Pressure  and  Size. — There  Avere 
various  methods  of  tamponing  the  vagina  for  uterine  hemorrhage  before 
the  introduction  of  Sims'  speculum,  such  as,  1,  the  crowding  of  as  many 
pledgets  of  cotton,  with  strings  attached,  into  the  vagina  through  a  cyhn- 
drical  or  plurivalve  speculum,  as  the  vagina  would  hold  ;  2,  the  passage 
of  a  greased  handkerchief  or  conical  bag  into  the  vagina  over  a  sj)eculum, 
and  the  filling  of  the  bag  to  the  mouth  with  pledgets  of  cotton  ;  the  sjDecu- 
lum  was  then  withdrawn,  and  the  tampon  removed  in  due  time  by  pulling 
on  the  bag  or  ends  of  the  handkerchief  projecting  from  the  vagina  ;  3,  the 
roller-bandage,  pushed  up  through  or  without  a  speculum,  and  removed 
by  drawing  on  its  projecting  end.  All  these  three  methods,  to  a  certain 
small  extent,  fulfil  their  pui-pose,  at  least,  in  so  far  that  for  a  time  the 
blood  finds  an  obstacle,  and  coagulation  is  induced,  until,  generally  in  a 
few  hours,  the  cotton  becomes  thoroughly  saturated  and  the  hemorrhage 
recommences.  And  it  cannot  well  be  otherwise,  for  the  loosely  distrib- 
uted balls  of  cotton,  in  a  dilatable  canal  like  the  vagina,  and  in  the  roomy 
vaginal  fornix,  exert  almost  no  pressure  on  the  source  whence  comes 
the  blood,  the  cervical  canal  and  external  os,  and  therefore  utterly  fail  in 
the  object  for  which  they  were  introduced,  mechanical  obstruction  to  the 
flow  of  blood  from  the  uterus.  AU  the  good  these  loose  cotton  tampons 
do  is  for  a  time  to  arrest  or  mitigate  the  hemorrhage  by  entangling  the 
blood  in  their  meshes  and  favoring  coagulation.  But  this  benefit  is  merely 
temporary,  and  a  speedy  renewal  of  the  tampon  is  required  with  the  same 
result,  until,  finally,  other  remedies  arrest  the  flow,  or  natui-e  takes  the 
matter  in  hand  and  removes  its  cause,  by  expelling  the  ovum,  or  placenta, 
or  polypus,  whichever  the  case  may  be  ;  or,  finally,  the  patient  succumbs. 
The  addition  of  astiingents  to  the  tampons  only  renders  their  removal 


214  MINOK    GYNECOLOGICAL    MAIilTPULATIONS. 

more  difficult  by  contracting  the  vagina,  but  does  not  arrest  the  hemor- 
rhage, since  the  bleeding  spot  is  not  touched  by  the  styptic.  The  tam- 
pons enclosed  in  a  handkerchief  or  bag  possess  the  advantage  of  being 
more  easily  removed,  and  the  bag,  if  thoroughly  distended,  may  exert  a 
more  steady  pressiu-e  on  the  cervix  than  the  loosely  scattered  tampons ; 
but  this  advantage  is  shght.  A  better  hemostatic  than  either  is  the  roller- 
bandage,  and  j)robably  better  still,  Foster's  lampwicking  tampon,  akeady 
described,  for  both  these  tamj)ons  are  in  one  piece,  they  are  tightly 
packed,  the  wicking  especially  is  very  porous,  and  by  its  absorption  of 
blood  wiU  form  a  pretty  solid  obstacle  to  fiu'ther  oozing.  Other  species  of 
tampons,  the  dilatable  rubber  bags,  so-called  colpeurynters,  certainly  are 
useful  and  efficient  in  cases  chiefly  where  the  vagina  is  veiy  distensible,  as 
during  pregnancy  ;  and  I  have  found  a  colpeurynter,  distended  to  its  ut- 
most with  cold  water,  not  only  the  most  convenient,  but  also  the  most 
efficient  means  of  controlling  hemonrhage  and  dilating  the  os  in  placenta 
previa.  But  for  the  non-puerperal  condition  they  are  generally  inad- 
missible, because  the  amount  of  distention  which  they  requu-e  to  make 
them  actually  hemostatic  is  not  long  borne  by  the  patient. 

The  loosely  packed  tampons,  as  above  described,  are  still  generally 
employed  as  hemostatics,  and  a  large  majority  of  the  profession  are  yet 
ignorant  of  the  only  sure  and  efficient  method  of  tamponing  the  vagina 
for  uterine  hemorrhage,  namely,  in  Sims'  jDOsition  through  his  speculum. 
Only  when  that  instrument  is  not  at  hand  aud  the  fingers  cannot  be  used 
as  a  substitute  through  rigidity  of  the  perineum  or  vagina,  is  the  practi- 
tioner (the  general  practitioner,  even)  justified  in  trifling  with  his  patient's 
health  and  life  by  resorting  to  the  almost  useless  tamponing  of  the  vagina 
through  a  cylindrical  or  plurivalve  speculum  in  a  case  where  the  hemor- 
rhage is  so  severe  as  to  call  for  a  tampon  at  all.  Every  practitioner  who 
takes  and  is  liable  to  meet  with  cases  of  uterine  hemorrhage  (aud  what 
general  practitioner  is  not  ?)  from  miscarriage,  fibroids,  polypi,  polypoid 
endometritis,  cancer,  should  not  only  possess  a  Sims  speculum,  but  know 
how  to  use  it  and  how  to  tampon  the  vagina  so  securely  that  not  a  drop  can 
escape  so  long  as  the  tampon  is  retained.  It  is  time  that  the  old  "  let  Avell 
enough  alone  "  excuse  be  denounced,  and  that  the  eminent  old-fashioned 
practitioner  who  "  never  lost  a  case "  from  hemorrhage  or  septicemia 
through  retention  of  the  placenta  after  abortion,  and  "  never  had  occasion 
to  sew  up  a  lacerated  perineum  in  a  practice  of  twenty-five  years,"  be  con- 
vinced that  not  everything  is  good  because  it  is  old  and  he  has  "  always 
done  it  and  succeeded  weU  with  it ; "  and  that  he  learn  that  the  only  proper 
way  to  apply  a  hemostatic  vaginal  tampon  is  in  the  manner  about  to  be 
described.  I  was  gi-eatly  surprised  to  see  in  a  recent  English  work  on  the 
"Diseases  of  "Women"  (Edis)  the  statement  that  the  tamponade  of  the 
vagina  for  hemorrhage  was  "  unscientific,  as  well  as  very  objectionable,  and 
should  never  be  resorted  to."  The  author  fails  to  inform  us  whether  it 
would  be  more  "  scientific  "  to  allow  the  woman  to  bleed  to  death  unless 
the  hemorrhage  is  arrested  by  internal  remedies,  or  a  sponge  or  laminaria 
tent  is  procured,  which  latter  is  his  practice  when  the  former  fails ;  and  he 


TAMPONADE    OF    THE    VAGINA.  215 

also  omits  to  explain  wherein  a  properly  disinfected  and  carefully  applied 
column  of  tampons  is  unscientific  when  it  is  used  merely  as  a  temporary 
measure  until  the  cause  of  the  hemorrhage  can  be  discovered  or  removed. 
The  Jirst  rule  in  such  cases  is  to  stop  the  bleeding  by  the  ve^nj  first  remedy  at 
hand  ;  the  second,  to  discover  the  cause  ;  and  the  third,  to  remove  it.  To 
Sims  and  his  pupil,  T.  Addis  Emmet,  belong  the  priority  of  the  following 
method  : 

The  patient  (with  empty  rectum  and  bladder)  occupies  the  left  lateral 
prone  position  ;  Sims'  speculum  is  introduced  and  the  cervix  exposed.  All 
coagula  and  fluid  blood  having  been  carefully  removed  by  the  dressing- 
forceps  and  damp  cotton,  a  disk-shaped  tampon  about  two  inches  in  diam- 
eter and  one-half  inch  thick  is  placed  over  the  cervix.  Another  such 
tampon  is  rolled  up  and  placed  behind,  another  in  front,  and  one  on  each 
side  of  the  cervix,  and  a  large  flat  one  again  over  all  these.  These  tam- 
pons are  recommended  by  Emmet  to  be  soaked  in  a  saturated  solution  of 
alum  and  squeezed  nearly  dry.  I  always  carbolize  the  tampons  in  a  one 
per  cent,  solution,  but  think  the  alum  solution  a  very  good  plan,  as  it  con- 
tracts the  vaginal  pouch  and  thereby  compresses  the  cervix.  Occasion- 
ally it  may  be  necessary  to  push  a  pledget  of  alum  cotton  into  the  cervical 
canal  and  thus  arrest  the  hemorrhage  until  the  whole  tampon  has  been 
firmly  placed.  The  oozing  of  blood  between  the  layers  of  cotton  hastens 
their  offensiveness. 

The  first  circle  and  layer  of  tampons  having  been  arranged,  as  de- 
scribed, and  the  vaginal  vault  thus  filled  and  the  cervix  compressed  in  all 
directions,  disk  after  disk  of  dampened  carbolized  cotton  (I  do  not  think 
it  necessary  to  alum  these  lower  layers)  is  laid  around  the  circle  of  the 
vagina,  filling  up  the  centre  at  the  last,  and  each  disk  and  each  layer  is 
gently  but  firmly  pressed  down  and  packed  tight  with  the  dressing-for- 
ceps. This  pressure  should  always  be  made  from  the  periphery  toward 
the  centre,  or  rather  from  the  anterior  vaginal  wall  toward  the  sacrum. 
As  the  cotton  is  thus  welded  and  pushed  up,  the  room  thus  made  is  filled 
by  new  pledgets,  until  the  vagina  is  distended  to  its  utmost  and  the  tam- 
pon has  reached  not  only  the  floor  of  the  pelvis,  but  is  parallel  with  the 
jDubic  arch.  After  a  final  thorough  survey  of  the  tampon  and  packing- 
down  of  any  loose  part,  the  dressing-forceps  hold  back  the  cotton  firmly 
with  widespread  blades,  and  the  speculum  is  carefully  dislodged  and  re- 
moved with  point  backward.  Considerable  care  is  required  not  to  dis- 
lodge the  tampon  in  this  maneuvre,  and  it  is  necessary  after  removal  of  the 
speculum  to  fill  the  space  thus  made  by  a  fresh  packing  tight  of  the  whole 
tampon,  and  perhaps  by  several  additional  disks.  I  always  introduce  two 
fingers  and  touch  the  surface  of  the  tampon  before  considering  the  work 
done  ;  in  this  way  I  am  able  to  detect  any  imperfection  in  the  pnckmg,  and 
remedy  it  by  direct  pressure.  The  whole  process  can  be  likened  to  noth- 
ing better  than  to  the  filling  of  a  carious  tooth  with  dry,  soft  pellets  of 
gold-leaf.  When  the  vagina  is  thus  tamponed,  there  is  absolutely  no 
chance  for  blood  to  ooze  throiagh,  and  only  after  twenty-four  hours  or 
longer  may  the  cotton  gradually  become  soaked  with  the  bloody  secretion 


216  MINOR    GYNECOLOGICAL    MANIPULATIONS. 

from  the  uterus  and  a  slight  oozing  from  the  vagina  appear.  But  this  is 
not  hemorrhage — merely  a  sign  that  that  particular  tampon  has  done  its 
duty  and  should  be  removed. 

This  tampon  should  not  be  retained  longer  than  twenty-four  hours.  It 
becomes  more  or  less  offensive  by  that  time,  even  when  thoroughly  carbo- 
lized  ;  besides,  it  is  so  easily  replaced  that  it  is  better  not  to  allow  it  to  re- 
main too  long.  While  the  vagina  is  distended  by  the  tampon  the  bowels 
should  not,  and  generally  cannot  be  moved  because  of  the  obstruction  of 
the  rectum  ;  if  moved,  the  tampon  may  be  displaced  and  the  hemorrhage 
recommence.  When  the  tampon  has  been  removed,  an  enema  may  be 
given  ;  or  a  laxative  may  have  been  taken  beforeliand,  and  the  tampon  is 
removed  when  its  action  is  imminent.  If  the  tampon  is  very  large  the 
bladder  may  require  emptying  by  the  catheter.  Or,  if  the  tampon  has 
been  placed  so  far  down,  its  pressure  on  the  neck  of  the  bladder  and  ure- 
thra may  give  rise  to  pain  and  tenesmus  ;  in  that  case,  the  patient  is  placed 
in  the  dorso-gluteal  position,  and  a  small  portion  of  the  tampon,  next  to 
the  urethra,  removed  with  forceps  or  notched  steel  tampon  screw.  The 
removal  of  the  tampon  is  an  easy  matter  after  the  speculum  has  once  been 


yxaxmam 


Fia.  97. — Sims'  Tampon  Extractor,  with  Closed  and  Open  Screw. 

introduced.  It  is  possible  to  remove  the  cotton  without  a  speculum  by 
guiding  the  tampon-extractor  into  the  vagina,  screwing  it  into  the  cotton, 
and  removing  piece  by  piece.  But  the  farther  it  is  necessary  to  reach  into 
the  vagina  the  more  irksome  does  this  proce  js  become,  and  I  am  there- 
fore in  the  habit  of  introducing  the  speculum  and  removing  all  the  cotton 
through  it.  The  at  first  compact  mass  of  cotton,  which  reached  from  side 
to  side  of  the  pelvic  cavity,  has  become  somewhat  loosened  by  the  utero- 
vaginal secretions,  and  it  is  not  a  difficult,  although  a  delicate,  task  to 
introduce  the  blade  of  the  Sims  behind  the  tampon  along  the  recto-vaginal 
wall.  At  first  the  speculum  should  be  introduced  only  a  short  distance, 
and  as  the  cotton  is  removed,  passed  up  to  its  full  length.  If  there  is  any 
difficulty,  the  first  layers  of  cotton  may  be  removed  without  a  speculum, 
and  the  latter  introduced  as  soon  as  room  is  made.  Layer  after  Vcljqy  of 
cotton  is  thus  removed  by  the  dressing-forceps  until  the  vagina  is  emp- 
tied. A  hot  carbolized  injection  is  then  given,  and  if  there  is  still 
hemoi'rhage  the  tampon  is  reapplied  in  the  same  manner.  If  the  flow  is 
slight,  the  tampon  need  not  be  so  large,  and  the  pledgets  may  be  soaked 
in  glycerine  and  water,  which  will  soothe  the  vaginal  walls  heated  by  the 
astringent  cotton. 

By  means  of  a  tampon  applied  in  this  manner  every  uterine  hemor- 
rhage can  be  controlled,  except,  perhaps,  during  labor,  when  I  think  a  col- 


TAMPONADE    OF    THE    VAGINA.  217 

pemynter  or  Barnes'  dilator  preferable.  In  inevitalDle  abortion  or  ute- 
rine fibroid  or  polypus,  the  hemorrhage  will  not  only  be  controlled  by  the 
tampon,  but  the  external  os  will  be  dilated  and  the  cervix  shortened  by  its 
pressure,  and  the  diagnosis  (if  necessary)  and  radical  treatment  thus  facili- 
tated. In  conjunction  with  these  tampons,  intra-uterine  treatment  for  the 
final  cure  of  the  hemorrhage  may  be  employed. 

The  difference  between  this  method  of  tamponing  the  vagina  and  the 
employment  of  a  column  of  tampons  as  supports  to  the  uterus  and  pehic 
vessels  is  only  one  of  degree,  the  hemostatic  tampon  being  much  larger 
than  the  supporting  or  dilating  tampon. 

8.  ^.s  an  Absorbent  of  Vaginal  and  Uterine  Discharges  and  a  Protective 
to  the  Sound  Parts  from  Caustic  Subiitances  Applied  to  Uterus  or  Cervix. — 
The  object  in  introducing  cotton  into  the  vagina  to  absorb  discharges  from 
that  canal  or  the  uterine  cavity,  is  to  prevent  these  discharges  from  infect- 
ing, excoriating,  or  soiling  the  parts  below,  whether  the  epidermis  of  these 
parts  be  intact  or  abraded.  Thus,  in  cancer  of  the  cervix,  or  profuse  dis- 
charge from  the  endometrium  and  endotrachelium  in  catarrhal  inflam- 
mation of  these  parts,  or  in  acute  or  chronic  vaginal  leucorrhea,  tamjDons 
— best  of  absorbent  cotton — are  introduced  into  the  vagina  to  catch  the 
secretion  and  prevent  it  from  escaping  and  excoriating  the  labia  and  ad- 
jacent parts,  and  soiling  the  linen.  Such  tampons  are  applied  in  the  ordi- 
nary manner,  disinfected,  if  necessary  ;  their  size  should  correspond  to  the 
capacity  of  the  vagina,  and  the  frequency  of  their  renewal  to  the  amount 
of  and  character  of  the  discharge.  As  with  every  other  variety  of  vagiual 
tampon  the  vagina  should  be  thoroughly  cleansed  of  debris  of  detached 
epithelium  and  coagulated  mucus  and  blood  by  copious  injections  imme- 
diately after  the  removal  of  the  tampon  and  before  the  introduction  of  a 
fresh  one. 

The  tampons  are  applied  through  either  of  the  forms  of  specula,  as  al- 
ready described,  'perhaps  quite  as  easily  and  effectually  through  the  cylin- 
der as  through  either  of  the  others. 

It  is  by  no  means  an  unimportant  matter  to  protect  the  labia,  vulva, 
and  thighs  from  excoriation  by  acrid  vaginal  discharges,  which  is  particu- 
larly liable  to  occur  even  from  an  ordinary  leucorrheal  flow,  in  stout 
women,  especially  in  warm  weather.  The  usual  astringent  vaginal  injec- 
tions do  not  suffice  for  this  purpose  ;  indeed,  the  very  frequency  with 
which  they  are  required  to  be  made,  aids  in  increasing  the  tenderness  of 
the  vulvo-vaginal  orifice.  An  absorbent  tampon,  previously  saturated  with 
an  astringent  and  then  dried,  answers  an  excellent  purpose  in  these  cases. 
It  may  be  mentioned  casually  that  an  excellent  application  for  excori- 
ated thighs  (acute  intertrigo  of  the  inguinal  furrow  and  the  cleft  between 
thighs  and  genital  organs)  is  the  ordinary  lead  or  diachylon  i^laster,  freshhj 
prepared,  spread  on  English  lint  or  linen  and  reapplied  two  or  three  times 
daily.  This  acts  not  only  as  a  protective,  but  as  a  healing  agent.  Tam- 
pons introduced  as  absorbents  of  profuse  utero-vaginal  dischai-ges  should 
be  renewed  at  least  every  twelve  hours. 

Professor  B.  S.  Schuitze,  of  Jena,  uses  the  tampon  as  a  means  of  diag- 


218  MINOR    GYNECOLOGICAL    MANIPULATIONS. 

nosing  an  endometritis.  He  states  that  tlie  usual  signs  given  in  the  books 
(tenderness  of  fundus  on  sounding,  profuse  serous  discharge,  suprapubic 
pain,  etc.)  are  vague,  wherein  no  doubt  he  is  correct ;  and  claims  that  the 
presence  of  pus  oozing  from  the  uterus  is  the  only  certain  evidence  of 
the  presence  of  endometritis.  To  detect  this  pus  and  distinguish  it  from  the 
secretions  of  the  cervical  and  vaginal  canals,  Schultze  employs  a  glycerine 
tampon  of  absorbent  cotton,  the  surface  of  which  is  coated  with  a  twenty- 
five  per  cent,  solution  of  glycerole  of  tannin.  This  tamj)on  is  placed 
against  the  cervix  through  a  sj)eculum,  the  vaginal  vault  having  first  been 
thoroughly  cleansed,  and  when  removed  after  twenty-four  hours  the  coagu- 
lated secretion  of  the  uterus  will  be  found  on  the  tampon  exactly  opposite 
the  OS  uteri.  The  cohesion  between  tampon  and  vaginal  walls  and  sur- 
face of  cervix  is  rendered  so  close  by  the  contraction  of  the  tannin  that  no 
uterine  secretion  can  ooze  past  the  tampon,  and  the  glycerine  attracts  the 
watery  secretions.  On  the  tampon  there  will  be  found  a  small  lump  of 
coagulated  uterine  secretion  ;  if  normal,  it  is  of  glutinous  appearance, 
transparent  or  but  slightly  opaque,  perhaps  tinged  violet  by  the  tannin  ; 
if  purulent,  the  color  is  entirely  diiferent,  opaque,  yellow,  or  greenish. 
The  difference  between  pus  from  the  uterine  cavity  proper  and  pus  from 
the  cervix  is,  that  the  cervical  pus  is  intimately  blended  with  the  peculiar 
tenacious  seci'etion  of  that  cavity,  but  the  uterine  pus  is  more  or  4ess  dis- 
tinct. This  purulent  secretion  may  not  be  constant,  indeed  is  more  com- 
mon and  profuse  immediately  before  or  after  the  mensti'ual  period,  or  it 
may  be  retained  a  few  days  and  then  be  discharged  in  one  gush.  Repeated 
examinations  with  the  tannin  tampon  should  therefore  be  made  before  de- 
ciding the  diagnosis. 

VI.    APPLICATIONS  TO  THE  ENDOMETRIUM. 

The  application  of  medicinal  agents  to  the  mucous  lining  of  the  uterine 
canal  is  naturally  divided  by  anatomical  and  practical  conditions  into  two 
sections  :  1.  Apphcations  to  the  mucous  membrane  lining  the  cavity  of  the 
cervix,  below  the  internal  os,  and  2,  applications  to  the  mucous  membrane 
of  the  uterine  cavity  proper,  above  the  internal  os. 

1.     Applications  to  the  Cavity  of  the  Cebvix. 

The  chief  points  of  difference  between  topical  apphcations  to  the  cavity 
of  the  cervix  and  to  the  uterine  cavity  proper  are  the  greater  accessibility 
and  tolerance  of  the  former  cavity.  While  any  instrument  or  medicinal 
agent  introduced  through  the  internal  os  may  set  up  violent  neuralgic  or 
inflammatory  action  in  the  uterus  or  its  adnexa  (as  has  already  been  stated 
in  speaking  of  the  use  of  the  sound),  the  cervical  canal  is  ordinarily  very 
little  susceptible  to  even  the  most  severe  treatment.  The  peculiar  forma- 
tion of  the  endoti'achelian  mucous  membrane,  and  the  comparatively  iso- 
lated position  of  the  cervix  (so  far  as  the  contig-uity  of  the  peritoneum  and 
large  lymphatic  plexuses  situated  between  the  broad  ligaments  is  con- 
cerned), are  probably  the  reasons  of  this  tolerance.    The  mucous  membrane 


APPLICATIONS    TO    THE    ENDOMETRIUM. 


219 


is  composed  of  numerous  racemose  glands  or  follicles  which,  arranged  in 
ridges  and  furnished  with  an  abundance  of  fibro-cellular  substratum,  be- 
come still  more  dense  and  tough  when  they  have  been  subjected  to  the 
continued  ii'ritation  of  a  catarrhal  inflammation.  And  this  is  the  very 
condition  when  applications  to  the  cervix  are  most  needed  and  performed. 

The  indications,  therefore,  for  applicatipns  to  the  cei-vical  cavity  are 
such  conditions  in  which  there  is  an  inflammation,  generally  subacute  or 
chronic,  of  the  mucous  membrane  of  the  cavity,  with  more  or  less  hyjDer- 
secretion  of  the  stringy,  ropy  mucus  peculiar  to  that  location.  The  vari- 
ous grades  of  this  affection  are  comprised  in  the  common  term  of  "  en- 
docervicitis,"  for  which  hybrid  word,  that  of  "  endotrachelitis "  [endo, 
within,  and  trachelos,  the  neck)  might  well  be  substituted.  They  are  all 
characterized  by  the  profuse  stringy  discharge  ah-eady  referred  to,  which 
may  be  either  translucent  or  discolored,  according  as  there  is  merely  a 
hypersecretion  or  an  actual  inflammation  with  loss  of  epithelium  and  sup- 
j3uration.  If  this  discharge  has  existed  for  any  length  of  time,  the  lips 
of  the  OS  are  eroded  (not  ul- 
cerated, since  there  is  only  a 
loss  of  the  epithelium,  no  ac- 
tual loss  of  substance),  and 
this  erosion  may  after  a  time 
be  accompanied  by  a  hyper- 
trophy of  the  papillse  of  the 
mucous  covering  of  the  cervix 
(papillary  erosion) ;  or  the  fol- 
licles may  become  occluded, 
distended,  and  project  fi'om 
the  cervix,  forming  the  "  ovu- 
la  Nabothi,"  or  they  may  dot 
the  surface  of  the  everted, 
red,  secreting  endotrachehum 
as  small  translucent  specks 
(follicular  erosion  or  cystic 
hyperplasia).  Figs.  100,  101, 
and  102.  "When  an  endo- 
trachelitis has  existed  for  some  time,  the  external  os  generally  gapes,  the 
lips  roll  out  and  the  eroded,  thickened  endotrachelian  mucous  membrane 
appears  to  view,  closely  simulating  ti-ue  ulceration  and,  of  course,  increas- 
ing the  circular  erosion  of  the  lips  already  spoken  of  (Fig.  98).  From 
this  gaping,  eroded  opening  usually  hangs  a  thick  plug  of  cloudy,  stiingy 
mucus,  which  resists  all  attempts  at  removal  by  forceps  and  cotton,  and 
has  to  be  drawn  and  broken  away,  as  it  were,  by  force  with  a  dry  sponge 
on  a  holder,  or  sucked  up  by  a  syringe.  This,  then,  is  the  class  of  cases 
in  which  local  applications  are  required  and,  indeed,  indispensable  to  a 
cure. 

A  fissure  or  laceration  often  precedes,  indeed  causes,  this  eversion  (or 
ectropium,  as  it  is  also  called),  and  the  endotrachehtis  is  but  a  secondai'y 


Fig.  98. — Circular  Evprsion  of  Mticoiis  Membrane  of  Cer- 
vical Canal  in  a  Subinvoluted  Uterus,  Simulating  Ulceratioa 
(Barnes). 


220 


MINOR    G-TNECOLOGICAL    MANIPULATIONS. 


affair,  the  result  of  the  laceration.  In  such  cases  it  is  usually  indispen- 
sable to  a  permanent  cure,  after  having  reduced  the  catarrh  and  hyper- 
plasia of  the  cervical  mucous  membrane,  to  close  the  laceration  by  an 
operation  first  devised  and  practised  by  Emmet,  and  now  become  deserv- 
edly popular  as  one  of  the  greatest  achievements  of  modern  gynecological 


Fig.  09. — Normal  NuUiparous  Cervix 
(P.  F.  M.). 


Fig.  100. — Catarrhal  Erosion  of  Cervix,  Super- 
ficial Desquamation  of  Epithelium,  First  Stage. 
(NuUipara. )  (P.  F.  M.) 


surgery.  Besides  parturition,  the  common  causes  of  endotrachelitis  are 
exposure  to  cold,  excessive  coition,  masturbation,  and  uterine  displace- 
ments ;  in  fact,  everything  which  produces  chronic  pelvic  congestion.  A 
very  common  companion,  or  at  least  consequence,  of  chronic  catarrh  of 
the  lining  membrane  of  the  cervix,  is  one  of  the  forms  of  erosion  of  the 
vaginal  mucous  membrane  covering  the  cervix  and  surrounding  the  exter- 
nal OS.  Such  conditions  are  not  uncommonly  met  with  in  virgins  and  nul- 
liparous  women,  and  to  be  successfully  treated  the  endotrachelitis  should 
first  be  cured  by  topical  applications  before  the  external  erosion  can  be  re- 


Pio.  101. — "Granular,"  Papillary  Erosion 
of  Cervix,  entire  Desquamation  of  Epitheli- 
um, Second  Stage,  with  Hypertrophy  of  Pa- 
pillfe.     (Nullipara.)  (P.  F.  M.) 


Fig.  109. —  "  Follicular"  Glandular  Erosion, 
with  Papillary  Erosion,  Hypertrophy  and  Oc- 
clusion of  Follicles,  and  Hypertrophy  of  Pa- 
pUlce.     (Nullipara.)  (P.  P.  M.) 


lieved.  As  a  rule,  both  affections  can  be  treated  at  the  same  time.  It 
is  a  matter  of  experience  that  such  catarrhal  affections  of  the  cervix,  com- 
phcated  by  eversion  or  not,  do  not  recover  under  mild  apjolications  by 
means  of  astringent  injections,  or  even  with  hot-water  irrigation.  While 
the  latter  undoubtedly  relieves  the  congestion  and  prepares  the  way  for 


APPLICATIOlSrS    TO    THE    ENDOMETRIUM.  221 

a  cure,  stronger  topical  agents  are  needed  to  remove  the  thickened  mucous 
membrane  and  set  up  fresli  healthy  action  in  the  tissues. 

A  frequent  indication  for  topical  applications  to  the  cervix  is  the  spread 
of  malignant  disease  up  from  the  external  os  ;  but  such  applications  re- 
quire to  be  of  the  most  powerful  agents. 

In  areolar  hyperplasia  of  the  uterus,  particularly  if  the  cervix  shares  to 
a  marked  deoree  in  the  enlargement,  the  introduction  of  alteratives  into 


Fig.  lOa.— Cervical  Mucus  Syringe.    A  piece  of  rubber  tubing  slippecl  over  tlie  nozzle  of  this  syringe  often 
answers  very  well  to  draw  tenacious  mucus  from  the  cervical  canal. 

the  cervical  cavity  may  aid  in  the  resolution  of  the  hyperplastic  tissue,  but 
such  applications  would  be  restricted  to  cases  in  which  the  more  efficient 
introduction  of  the  agent  into  the  uterine  cavity  proper  is  inadmissible. 

Agents. — To  be  of  any  service  in  the  chronic,  notoriously  intractable 
catarrh  of  the  cervical  cavity,  apphcations  must  be  thorough  and  powerful. 
"Whatever,  therefore,  can  safely  be  applied  to  the  outer  surface  of  the  va- 
ginal portion  of  the  cervix  may  (with  somewhat  less  safety,  but  still  prop- 
erly) be  used  in  the  cervical  canal.  But  the  internal  os  should  (except  in 
the  cases  hereafter  to  be  specified)  always  be  regarded  as  the  limit  of  such 
powerful  measures. 

We  may  thus  apply  the  fuming  nitric,  pure  carbohc,  or  chromic  acid  to 
the  cervical  cavity  ;  or  the  solid  stick  of  nitrate  of  silver  ;  or,  if  we  desire 
to  produce  a  decided  slough,  as  in  malignant  disease,  the  saturated  solu- 
tion of  chloride  of  zinc  (as  described  under  ApiDlications  to  the  Cervix)  or 
the  caustic  potash  or  solution  of  pernitrate  of  mercury,  or,  what  is  often 
better  still,  the  actual  cautery.  But  it  is  all-important  to  remember  that 
the  sloughs  of  all  the  substances  named,  from  the  nitric  acid  to  the  nitrate 
of  mercury  (excepting  only  the  pure  carbolic),  produce  cicatricial  contrac- 
tion, and  that  they  should  therefore  not  be  applied  to  a  ceiwical  canal 
unless  such  contraction  is  desired.  A  mere  superficial  aj)plication,  how- 
ever, will  produce  no  slough  and  no  contraction,  especially  if  nitric  acid  is 
used.  This  agent,  therefore,  is  a  very  useful  remedy  in  chronic  endo- 
trachelitis,  characterized  by  hypersecretion  and  enlarged  follicles.  Another 
excellent  application  in  this  affection  is  the  iodized  phenol  (tincture  of 
iodine  and  pure  carbohc  acid,  equal  parts)  Avhich  may  be  applied  every  other 
day  or  oftener,  until  the  cervical  cavity  assumes  a  more  healthy  appearance. 
When  this  occurs,  no  matter  what  the  agent  used,  a  milder  apphcation, 
such  as  plain  tincture  of  iodine,  tannin  and  glycerine  (equal  parts),  or  tan- 
nin in  powder,  or  iodoform  and  tannin,  or  the  pencil  of  sulphate  of  copper 
or  zinc,  or,  what  is  best  of  ah,  a  solution  of  nitrate  of  silver  (  3  ss.  to  3  j-  to 
3J.  of  water)  should  be  applied  every  two  or  three  days  until  healthy 
epithelium  covers  the  eroded  mucous  membrane. 

When  the  tough  mucous  membrane  and  enlarged  glands  resist  even 
the  strong  escharotics  first  mentioned,  we  might  resort  to  the  last  two  in 
the  list  of  strong  agents— the  acid  pernitrate  of  mercui-y  and  the  caustic 


222  MIN^OR    GYNECOLOGICAL    MAISTIPULATIONS. 

potash  (potassa  fusa,  or  potassa  cum  calce,  which  latter  is  preferable  be- 
cause it  is  not  so  powerfully  caustic  and  does  not  diffuse).  But  the  effect 
of  these  two  diffusible  agents  is  not  so  easily  controlled,  and  we  cannot 
tell  whether  the  slough  produced  and  the  cicatricial  contraction  ensuing 
may  not  largely  exceed  safety  and  our  wishes. 

A  far  safer  and  also,  I  think,  more  efKcient  escharotic  is  the  actual 
cautery,  applied  either  as  a  hot  iron,  or  the  dull  red  platinum  tip  of  a  gal- 
vano-caustic  battery  or  the  thermo-cautery.  Its  application  is  instan- 
taneous, not  painful,  and  the  slough  formed  is  not  too  deep  if  the  heat  is 
not  too  intense  and  its  contact  too  thorough.  In  the  cervical  cavity  this 
application  is  generally  perfectly  safe  ;  beyond  the  internal  os,  however, 
its  use  becomes  decidedly  hazardous.  Should  this  agent  fail,  or  should  it 
appear  desirable  to  remove  the  hyperplastic  follicles  more  rapidly,  and  at 
the  same  time  stimulate  the  mucous  membrane  thoroughly,  we  may  do  so 
with  an  instrument  which  we  have  entirely  under  control,  namely,  the 
sharp  cutting  curette  of  Sims  (see  chapter  on  Curetting).  With  it  the 
hyperplastic  tissue  is  removed  with  ease,  rapidity,  safety,  and  comparative 
absence  of  pain.  It  is  well  to  paint  over  the  fresh  surface  with  tincture  of 
iodine  or  a  solution  of  nitrate  of  silver  immediately  after  the  curetting. 
Sims  says  that  without  the  sharp  curette  he  would  despair  of  curing  very 
many  cases  of  chronic  endotrachelitis.  If  thoroughly  done,  the  curetting 
will  not  require  repetition. 

In  a  large  proportion  of  cases,  almost  exclusively  in  single  or  sterile 
women,  the  endotrachelian  catarrh  (and,  post  hoc  and  propter  hoc,  the  ste- 
rility) is  due  to  a  narrow  external  os,  which  j^revents  the  free  discharge 
of  the  normal  cervical  secretion.  The  pent-up  discharge  gradually  becomes 
acrid,  irritates  the  cervical  mucosa,  Avhich  pours  forth  a  fresh  suj^ply  ;  this 
increases  the  irritation,  until  we  finally  have  a  decided  catarrhal  inflam- 
mation of  the  cervical  canal  and  a  dilatation  of  its  follicles.  It  will  give 
but  temporary  relief  to  remove  the  retained  discharge  with  a  cervical 
syringe  or  cotton-wrapped  stick.  Indeed,  the  viscid,  tenacious,  discolored 
(yellowish  or  brownish)  mucus  frequently  resists  all  efforts  for  its  removal. 
The  curette  cannot  be  introduced  through  the  narrow  os,  and  even  if  the 
follicles  were  scraped  away  the  disease  would  return,  because  the  primary 
exciting  cause,  the  constricted  external  orifice,  still  exists.  We  must, 
therefore,  begin  the  treatment  by  enlarging  this  orifice,  and  this  may  be 
done  either  with  the  dilator  or  the  knife.  When  a  thick  plug  of  mucus 
is  seen  hanging  from  the  external  os,  or  the  removal  of  the  sound  from 
the  uterine  cavity  is  followed  by  a  gush  of  viscid  mucus  which  has  been 
liberated  by  that  instrument,  we  can  generally  assume  that  the  case  is  one 
of  retention  of  endotrachelian  secretion,  and  that  our  first  step  should  be 
to  give  that  secretion  a  free  outlet.  The  condition  in  such  cases  is  ex- 
plained by  the  accompanying  cut,  which  shows  a  long  cervix  with  narrow 
external  orifice  and  its  cavity  dilated  by  the  accumulated  secretion,  the 
viscidity  of  which  prevents  its  flowing  through  the  small  outlet,  as  a  fluid 
discharge  probably  would.  I  have  frequently  procured  the  expulsion  of 
this  accumulation  in  a  gush  by  pressing  on  the  posterior  surface  of  the 


APPLICATIONS    TO    THE    ENDOMETPvIUM. 


223 


cervix  with  the  finger  or  depressor.  The  indication  in  such  cases  is  to 
dilate  or  incise  the  external  os  sufficiently  to  permit  the  free  escape  of  the 
secretion.  A  dilatation  will  doubtless  suffice  for  temporary  relief,  but  the 
orifice  will  certainly  contract  again  unless  the  dilatation  is  frequently  re- 
peated. We  should  remember  that  applications  to  the  cervix  will  probably 
be  needed  for  some  time,  and  that  patency  of  the  cavity  is  desirable  for 
that  purpose  ;  furthei*,  that  it  is  not  only  the  endo- 
trachelitis  which  we  must  cure,  but  also  the  steriHty 
so  generally  accompanying  the  catarrh.  We  must 
not  only  remove  and  prevent  the  re-formation  of  the 
acrid,  tenacious  mucus,  which  prevents  the  sperma- 
tozoa from  passing  into  and  through  the  cervical  ca- 
nal, but  we  must  also  Iceej)  the  door  sufficiently  open 
to  give  them  free  admission.  We  must,  therefore, 
secure  permanent  patency  of  the  external  os,  and 
this  is  best  attained  by  a  combination  of  the  two 
methods,  the  knife  and  dilatation.  I  should  advise, 
first  to  incise  the  lips  of  the  external  os,  not  bi- 
laterally only,  but  quadrilaterally — make  what  is 
known  as  a  crucial  incision,  and  make  it  so  deep  as 
to  open  the  external  os  nearly  or  quite  to  the  size 
of  the  dilated  cervical  canal  (as  shown  by  the  dot- 
ted lines  in  the  cut,  Fig.  104).  The  particulars  of 
this  little  operation  are  given  in  the  section  on  Dil- 
atation of  the. Uterus  by  Incision. 

The  division  of  the  external  os  uteri,  when  pei- 
formed  for  cervical  catarrh,  is  best  followed  at  once  by  the  thorouo-li  use 
of  the  sharp  curette  (as  hereafter  to  be  described),  and  the  scraped  surface 
is  immediately  cauterized  thoroughly  by  one  of  the  stronger  caustics,  of 
which  chemically  pure  nitric  acid  is  by  far  the  most  efficient.  When  the 
slough  of  this  application  has  separated,  milder  caustics,  such  as  the  iodized 
phenol,  solid  stick  of  nitrate  of  silver,  or  sulphate  of  copper  or  zinc,  pure 
carbolic  acid  or  tincture  of  iodine  should  be  employed  once  or  twice  a 
week  until  the  catarrh  is  cured.  Should  the  external  os  show  a  tendency 
to  contract  during  this  treatment,  it  must  be  kept  patent  by  dilatation  with 
a  steel  screw-dilator,  and  perhaps  by  a  cotton  plug  slij)ped  from  the  ap- 
plicator. If  thought  desirable,  this  plug  may  be  soaked  in  iodized  phenol, 
tincture  of  iodine,  or  carbolic  acid,  whereby  a  more  lasting  effect  is  obtained. 

The  cure  of  an  endotrachehtis  of  long  standing  is  always  a  matter  of 
several  months,  perhaps  even  a  year  or  longer.  A  speedy  recovery  should, 
therefore,  never  be  promised,  although  the  hope  of  a  sure  cure  may  gen- 
erally be  held  out.  Kelapses,  however,  are  very  liable  to  occur,  and  this 
fact  should  be  mentioned  in  stating  the  j^rognosis  to  the  patient.  It  is 
well  to  bear  in  mind  that  pregnancy  increases  the  hypersecretion  from  the 
endotrachelium,  especially  if  the  cervix  is  lacerated  and  everted,  and  that 
no  treatment  but  very  mild  local  astringents  in  injections  should  be  used 
until  after  delivery.     The  small  operation  just  described,  as  well  as  all  ap- 


FiG.  104.— Dilatation  of  Cer- 
vical Cavity  and  Retention  of 
Mucus  in  Endotrachelitis  by 
Narrow  External  Os.  Dotted 
lines  show  incisions  (P.  F.  M.). 


224  mijS"or  gynecological  manipulations. 

plications  to  the  enclotrachelian  cavity,  are  best  performed  through  a  Sims' 
sx5eculum — that  is  uuderstood.  Still,  a  large  tubular  or  bivalve  might 
answer  very  well. 

Counter-indications  and  Danger?. — The  counter-indications  to  the  appli- 
cation of  caustics,  or  the  curette  to  the  cervical  cavity,  are  always  (besides 
the  invariable  one  of  j)regnancy)  the  presence  of  acute  or  subacute  inflam- 
mation of  the  uterus  or  its  adnexa.  The  dangers  are  the  rekindling  of 
such  inflammation,  if  it  once  existed,  or  of  producing  it  for  the  time,  if  the 
patient  happens  to  be  in  a  susceptible  condition.  Thus,  in  a  case  of  oper- 
ation for  laceration  of  the  cervix,  in  which  a  small  cervico-vaginal  fistula 
remained  at  the  angle  of  the  laceration,  the  remainder  of  the  rent  having 
fully  united,  the  cauterization  of  the  fistulous  track  with  the  stick  of  nitrate 
of  silver  resulted  in  a  circumscribed  pelvic  cellulitis  of  the  size  of  half  a 
lemon  in  the  supra-vaginal  cellular  tissue  immediately  adjoining  the  fist- 
ula. This  exudation  disappeared  in  two  weeks  and  the  fistula  then  proved 
to  be  healed.  There  are  the  same  counter-indications  to,  and  the  same 
dangers  from,  any  application  to  the  uterus.  A  careful  examination  and 
perhaps  previous  experience  with  the  case  will  enable  the  physician  to 
judge  whether  his  j)atient  is  likely  to  bear  local  treatment  well. 

When,  however,  the  circum-uterine  inflammation  is  confined  to  the 
lymphatic  vessels  and  glands  it  should  be  considered  that  this  very 
lymphangitis  may  be  due  to  transmission  from  the  inflamed  cervical  mu- 
cous membrane,  and  that,  so  long  as  the  catarrh  exists,  the  sympathetic 
lymphangitis  persists  with  it.  The  catarrh  must  therefore  be  treated  if 
the  lymphangitis  is  to  be  reheved.  The  question  in  these,  cases  as  to  the 
safety  of  local  treatment  is  merely  one  of  differential  diagnosis  between 
chronic  pelvic  lymphangitis  and  lymphadenitis  and  chronic  pelvic  cellu- 
litis, a  distinction  not  so  very  difficult  to  the  jDractised  touch,  if  one  re- 
members that  inflamed  lymphatic  glands  are  generally  movable  and  exist 
on  either  side  of  and  behind  the  cervix  only  as  small  bean-like  bodies,  and 
that  lymphatic  vessels  are  tortuous  and  movable,  whereas  the  exudations 
of  chronic  pelvic  cellulitis  are  irregular,  flat,  entirely  immovable,  and  usu- 
ally less  painful  nodules.  In  lymphangitis,  also,  the  uterus  is  movable ; 
in  chronic  cellulitis,  more  or  less  fixed. 

The  precautions  to  be  employed  will,  therefore,  depend  upon  the  exi- 
gencies of  each  case.  Still,  the  general  rule  should  be  observed,  not  to 
apj)ly  any  caustic  agent  so  thoroughly  as  to  cause  a  mutilation  of  the 
cervix  by  the  slough  it  produces,  therefore  to  be  careful  to  apply  such 
caustics  as  are  followed  by  cicatricial  contraction  (nitric  acid,  chromic  acid, 
solid  nitrate  of  silver,  acid  nitrate  of  mei'cury)  only  to  a  cervical  canal 
which  is  larger  than  it  should  be,  and  which  will  permit  such  contraction 
without  injury  to  the  future  health  of  the  patient.  Nitric  acid,  when 
deeply  applied,  will  cause  a  slough  ;  but  if  touched  but  lightly  on  an 
abraded  surface  produces  merely  a  supei-ficial  film  of  albuminate,  and  acts 
more  as  a  stimulant  than  a  caustic.  We  should  therefore  apply  it  thor- 
oughly only  when  we  wish  to  destroy  tissue  and  produce  cicatricial  con- 
traction.    By  bearing  this  rule  in  mind,  the  frequent  cases  of  stenosis  of 


APPLICATIOIifS    TO    THE    ENDOMETRIUM.  225 

the  cervical  canal  and  external  os  will  be  avoided  which  are  met  with  by 
gynecologists  as  the  result  of  the  careless  application  of  nitric  acid.  The 
same  applies  quite  as  much  to  the  sohd  nitrate  of  silver. 

Methods. — Whichever  speculum  wiU  thoroughly  expose  the  cer-vdcal 
canal  and  permit  the  introduction  of  an  applicator  or  curette  into  it  will 
answer  for  the  purpose  of  endotrachelian  medication.  The  nitrate  of  silver 
or  sulphate  of  copper  stick  is  apjDlied  by  a  long  caustic  holder  or  in  a  quill, 
or  held  by  long  dressing-forceps ;  the  chromic,  carbolic,  and  nitric  acids 
and  nitrate  of  mercury  on  a  glass  or  wooden  rod.  The  wood  soaks  up  the 
fluid  and  prevents  its  dropping,  and  is  therefore  preferable  to  the  glass. 
The  iodine,  iodized  phenol,  etc.,  are  best  appHed  by  a  brush  or  cotton- 
wrapped  screw-stick,  which,  of  course,  can  be  equally  well  used  for  the 
other  agents  if  care  is  taken  to  carefully  wipe  off  all  excess  from  the  cot- 
ton. As  in  making  applications  to  the  surface  of  the  cervix,  the  vagina 
should  be  protected  from  any  excess  of  the  fluid  by  packing  a  layer  of 
cotton  wadding  under  the  cervix,  which  cotton  may  be  soaked  in  oil,  salt- 
water, or  a  solution  of  bicarbonate  of  soda  to  neutralize  the  caustic,  and  is 
removed  with  the  speculum. 

It  is  well  to  moj)  up  the  excess  of  the  strong  caustics  before  placing  the 
usual  vaseline  or  glycerine  tampon  over  the  cervix.  But  if  a  more  thorough 
effect  is  desired  from  the  milder  alteratives  and  stimulants  (iodine,  iodized 
phenol),  the  cotton  plug  described  above  may  be  soaked  in  the  agent  and 
introduced  on  the  slide  a^^plicator,  to  be  removed  after  eighteen  to  twenty- 
four  hours.  The  powders  (iodoform,  iodoform  and  tannin)  are  either 
thrown  into  the  cervix  by  a  spoon  or  spatula,  or  blown  in  by  an  insufflator, 
and  are  allowed  to  remain  until  eliminated  with  the  vaginal  secretions.  If 
it  is  desired  to  dejolete  the  cervix  and  allay  irritation,  a  glycerine  tampon 
should  be  apj)lied  ;  but  if  the  effect  of  the  application  is  to  be  astringent, 
a  vaseline  tampon  is  preferable.  The  sloughs  from  the  strong  caustics 
come  away  in  from  five  to  seven  days  (or  more,  if  very  deep)  ;  the  albumi- 
nate formed  by  the  milder  agents  disappears  within  two  days.  The  time 
for  rejoetition  of  the  application  varies  therefore  with  the  character  and 
strength  of  the  agent  applied,  the  thoroughness  of  its  use,  and  with  the 
severity  of  the  affection.  Strong  caustics  require  to  be  applied  only  once  or 
twice,  to  be  followed  by  the  milder  agents,  which  should  be  used  two  or 
three  times  a  week  as  long  as  the  case  calls  for  them,  and  may  need  fre- 
quent changing. 

I  have  devoted  so  much  space  to  the  discussion  of  applications  to  the 
cervical  canal,  because  catarrhal  hyjoer secretion  of  that  j)art  is  exceedingly 
common  and  a  very  frequent,  often  unsuspected,  cause  of  sterility  and 
annoying  backache  ;  further,  because  its  treatment  should  be  energetic  to 
be  successful,  and  even  then  is  not  Hkely  to  anticipate  the  expected  period 
of  cau'e. 

15 


226  MINOR    GYNECOLOGICAL    MANIPULATIONS. 


2.  Applications  to  the  Mucous  Membrane  of  the  Uterine  Cavity  Pkopee. 

The  indications  for  intra-uterine  applications  are  exceedingly  simple. 
They  may  be  enumerated  under  five  heads  :  1.  Endometritis,  or  uterine 
catarrh,  in  its  chronic  form.  2.  Hemorrhage  from  the  cavity  of  the  ute- 
rus. 3.  Subinvolution  and  areolar  hyperplasia  of  the  utenis.  4.  Intra- 
uterine vegetations,  or  malignant  disease.  5.  Defective  development,  or 
atrophy  of  the  uterus  ;  amenorrhea. 

1.  Chronic  Endometritis. — Although  Emmet  ignores  the  existence  of 
this  disease,  I  confess  I  do  not  understand  why  there  should  not  be  a 
catarrhal  affection  of  the  mucous  membrane  of  the  uterine  cavity  as  well 
as  of  all  other  mucous  membranes  in  the  body  ;  and  I  do  not  see  how  an 
endosalpyngitis,  which  he  admits  as  the  result  of  venereal  infection,  can 
exist  unless  by  direct  transmission  of  the  virus  through  the  mucous  mem- 
brane of  the  uterine  cavity.  Call  it  what  we  will,  there  certainly  are  nu- 
merous cases  in  which  that  mucous  membrane  is  in  a  condition  of  chronic 
hyperemia  (produced  by  exjDosure  to  cold,  over-exertion,  excessive  coition, 
repeated  miscarriages,  sluggish  portal  circulation,  etc.),  which  hyperemia 
may  gradually  result  in  hyj^er-secretion,  which  again  produces  a  macera- 
tion of  the  intra-uterine  epithelium  and  an  increased  muco-purulent  dis- 
charge. The  diagTiosis  of  chronic  endometritis  may  be  made  either  from 
the  oozing  of  this  muco-purulent  discharge  from  the  os  (its  intra-uterine 
origin  being  distinguishable  from  the  cervical  by  the  entire  absence  of  the 
viscidity  peculiar  to  the  latter,  and  by  the  tampon  test  of  Schultze,  al- 
ready described),  or  from  unusual  tenderness  or  bleeding  of  the  endome- 
trium on  careful  sounding,  or  from  a  conjunction  of  these  signs  together 
with  otherwise  tmexplained  abdominal  weight  and  dragging  pelvic  pains. 
The  occurrence  of  menorrhagia  may  confirm  the  diagnosis. 

It  is  of  very  little  avail  to  treat  this  affection,  when  once  it  has  become 
chronic,  by  other  than  local  means,  by  agents  applied  directly  to  the  endo- 
metrium. The  analogy  between  chronic,  nasal,  laryngeal,  and  uterine 
catarrh  in  this  respect  is  perfect. 

The  indications  for  the  treatment  of  a  chronic  endometritis  are  suffi- 
ciently explicit  and  numerous :  the  exhausting  drain  of  the  discharge,  the 
aching,  dragging  pain  in  the  lower  abdomen,  the  constant  backache,  the 
reflex  neuralgise,  lastly,  the  sterihty  induced  by  the  discharge  and  the  un- 
favorable condition  of  the  irritable  endometrium  for  nidation  of  the  ovum, 
all  these  are  sufficient  reasons  why  the  disease  should  not  be  neglected. 
Besides,  the  discharge  fi'om  the  uterine  cavity  is  very  prone  to  irritate  the 
endotrachelium  and  produce  a  h^'per- secretion  from  that  part.  Indeed,  I 
dare  say  there  are  comparatively  few  cases  of  pure,  uncomplicated  chronic 
endometritis.  The  cases,  however,  in  which  the  catarrhal  affection  has  not 
spread  above  the  internal  os  are  by  far  more  common.  Again,  a  dis- 
charge from  the  uterus  may  produce  a  vaginal  catarrh,  and  so  the  anno}'- 
ance  increases. 

In  conjunction  with  remedies  applied  directly  to  the  endometrium,  the 


APPLICATIONS  TO  MUCOUS  MEMBRANE  OF  UTERINE  CAVITY.    227 

usual  depleting  measures  for  the  pelvic  organs  are  indicated,  such  as  gly- 
cerine tampons,  hot  injections,  saline  laxatives ;  and  the  general  health 
needs  building  up. 

2.  Uterine  Hemorrhage. — The  causes  of  pathological  hemorrhage  from 
the  mucous  membrane  of  the  uterus  may  be  either  constitutional  (cardiac, 
hepatic,  or  renal  disease,  acute  febrile  affections,  exanthemata,  hemor- 
rhagic diathesis,  abdominal  plethora),  or  local  (polypoid  degeneration,  or 
hyperplasia  of  the  uterine  mucosa,  fibroids  of  the  uterus,  malignant  dis- 
ease of  the  uterus,  laceration  of  the  cervix,  endometritis,  ovarian  conges- 
tion), or  a  combination  of  both.  To  treat  uterine  hemorrhage  depending 
on  one  of  the  above-named  constitutional  causes  by  local  appUcations 
would  manifestly  be  irrational  and  of  but  temporary  benefit.  And  equally 
futile  would  it  be  to  give  hemostatic  medicines  for  the  ai'rest  of  a  metror- 
rhagia caused  by  poh'poid  vegetations  or  cancerous  disease.  As  regards 
fibroids,  however,  agents  which  cut  off  the  blood  supply  from  the  tumor 
by  contracting  the  uterus,  notably  ergot,  form  a  decided  exception  to  this 
rule.  But  the  hemorrhage  from  the  villi  of  a  cervical  epithehoma  or  a 
hyperplastic  uterine  mucosa  is  very  little  affected  by  general  hemostatics. 
The  best  results  are  undoubtedly  obtained  by  combining  both  methods  of 
treatment ;  and  I  am,  therefore,  in  the  habit  of  prescribing  hemostatic 
medicines  (ergot,  gossypium,  cannabis  indica,  aromatic  sulphuric  acid, 
etc.),  while  using  local  medication.  A  radical  cure  will,  however,  be 
achieved  only  by  such  treatment  as  removes  the  cause,  constitutional  or 
local,  of  the  hemorrhage. 

In  making  the  diagnosis  of  uterine  hemorrhage  it  may  be  well  to  ex- 
clude hemorrhage  from  the  vagina  or  cervix  (as  in  laceration  or  malignant 
disease  of  the  cervix)  before  deciding  on  the  proper  medication  ;  and  this 
is  done  by  exjDosing  the  parts  with  the  speculum. 

The  effect  of  toj^ical  hemostatic  remedies  is  usually  a  rapid  one,  but 
they  may  have  to  be  frequently  repeated  unless  the  cause  of  the  hemor- 
rhage is  at  the  same  time  removed. 

3.  Subinvolution  and  Areolar  Hyperplasia  of  the  Uterus. — An  exceed- 
ingly common  affection  with  all  women  who  have  miscarried  or  borne 
children  is  deficient  involution  of  the  uterus.  This  may  depend  on  local 
factors  which  interfere  with  the  proper  physiological  involution  of  all  the 
genital  organs  after  childbirth,  such  as  local  injui-ies  to  the  uterus  and  ad- 
nexa  (laceration  of  cervix  or  perineum,  displacements  of  uterus),  jDehdc 
peritonitis  or  cellulitis,  too  early  rising  from  the  lying-in  couch,  endome- 
tritis, metritis  ;  or  it  may  be  due  to  constitutional  debility  and  want  of 
tone.  A  subinvolution  of  the  uterus,  which  is  neglected  or  does  not  yield 
to  remedies,  does  not,  in  my  opinion,  remain  a  subinvolution  always  ;  but, 
after  a  certain  period,  varying  between  several  months  and  several  years, 
the  intermuscular  cellular  or  areolar  tissue  begins  to  enlarge  and  gradu- 
ally encroaches  upon  and  compresses  the  formerW  abnormally  developed 
muscular  fibres,  the  latter  lose  their  softness  and  succulence,  and  the  are- 
olar tissue  becomes  dense,  and  at  last  almost  fibrous ;  the  soft  subinvolu- 
tion has  passed  into  the  hard  areolar  hyperplasia.     In  the  words  of  Scan- 


228  MIlSrOR    GYNECOLOGICAL    MAISTIPULATIOlSrS. 

zoni,  tlie  father  of  "  cbronic  metritis,"  which  is  identical  with  what  we  now 
call  areolar  hyperplasia,  the  stage  of  infiltration  merges  into  that  of  in- 
duration. Skene  calls  the  latter  condition  sclerosis  of  the  uterus.  The 
large  majority  of  cases  of  areolar  hyperplasia,  in  my  opinion,  date  from  a 
miscarriage  or  confinement,  subinvolution,  of  course,  being  the  ioitial 
stage  of  the  affection.  But  rarely  do  I  meet  with  a  case  of  diffuse  areolar 
hyperplasia  of  the  whole  uterus  in  a  nullipara.  Still,  I  will  not  deny  that 
causes  which  produce  and  maintain  a  chronic  congestion  of  the  uterus 
(such  as  repeated  temperature  shocks,  excessive  or  unnatural  coition,  cold 
syringing  after  intercourse,  unsatisfied  sexual  excitement)  may  in  time 
produce  a  condition  identical  with  areolar  hyperplasia. 

The  local  symptoms  (pelvic  weight,  pressure,  backache,  dysuria,  dys- 
chezia,  ovaralgia)  and  the  constitutional  signs  (the  various  hystero-neu- 
roses,  general  anemia,  melanchoha,  etc.)  present  an  array  of  ailments  so 
distressing  and  persistent  as  to  call  for  any  means  by  which  relief  may  be 
obtained.  Among  such  means  undoubtedly  are  the  intra-uterine  apphca- 
tions  of  stimulating,  absorbent,  and  alterative  agents.  But  to  be  of  ser- 
vice such  appUcations  should  be  thorough,  persistent,  and  frequent,  far 
more  so  even  than  in  chronic  endometritis,  and  they  should  always  be 
combined  with  hot-water  injections,  glycerine  tampons,  saline  laxatives, 
and  general  tonics. 

4.  Intra-uterine  Vegetations  or  Malignant  Disease. — "While  some  gyne- 
cologists, disciples  of  Lombe  Atthill,  of  Dublin,  still  endeavor  to  destroy 
vegetations  of  the  endometrium  by  the  aiDplication  of  powerful  caustics, 
chiefly  fuming  nitric  acid,  the  majority  follow  the  lead  of  Sims  and 
Thomas,  and  remove  the  vegetations  with  the  curette,  preferably  the  blunt 
instrument  of  Thomas.  This  latter  method  is  so  much  more  effectual, 
rapid,  convenient,  and  safe  than  the  tedious,  painful,  and  more  or  less 
superficial  cauterization,  that  with  us  the  curette  has  become  the  favorite 
means  of  treating  polypoid  endometritis.  But  cases  are  not  unfrequently 
met  with  in  which  a  more  positive  local  effect  seems  necessary  than  the 
mere  scraping  of  the  vegetations,  cases  in  which  a  deeper  layer  of  the 
endometran  mucosa  requires  to  be  removed  than  would  be  justifiable  with 
the  curette  ;  and  here  it  may  be  necessary  to  supplement  the  curetting 
by  an  application  of  fuming  nitric  acid,  chromic  acid  (1  :  2),  iodized 
phenol,  or  solution  of  persulphate  of  iron.  Such  cases  are  generally  those 
in  which  the  hemorrhage  continues  or  returns  after  the  scraping,  and  the 
repeated  use  of  the  curette  fails  to  remove  additional  vegetations.  The  ec- 
tatic  and  debilitated  blood-vessels  of  the  endometrium  seem  unable  to  con- 
tract, and  the  only  means  of  preventing  the  oozing  from  their  torn  and  gap- 
ing orifices  is  to  utterly  destroy  them.  This,  one  of  the  caustics  named 
effectually  does,  and  after  the  separation  of  the  slough  a  new,  and  pre- 
sumably more  healthy,  mucous  membrane  has  been  formed.  It  is  evident 
that  unusual  care  should  be  employed  not  to  apply  the  escharotic  too 
deeply  to  the  denuded  endometrium.  But  there  are  other  cases  in  which 
an  application  of  a  milder  caustic,  astringent,  or  alterative  is  beneficial 
after  curetting,  and  these  are,  when  the  uterus  is  subinvoluted,  hyper- 


APPLICATIOlSrS  TO  MUCOUS  MBMBRAISTE  OF  UTERINE  CAVITY.    229 

plastic,  flabby,  apparently  incapable  of  energetic  contraction  and  involu- 
tion ;  cases  when  the  continued  passive  hyperemia  of  the  organ,  after  the 
removal  of  the  vegetations  and  the  pulpy,  thickened  mucous  lining,  will 
soon  result  in  the  reproduction  of  the  vegetations.  In  such  cases  I  always 
swab  the  uterine  cavity  with  Churchill's  tincture  of  iodine,  in  bad  cases 
even  with  iodized  phenol,  and  perhaps  leave  a  plug  of  cotton  soaked  in 
the  fluid  in  the  cavity  for  twenty-four  hours.  These  applications  need 
weekly  repetition,  or  oftener,  and  then  serve  also  to  fulfil  the  previously 
mentioned  indication  of  reducing  uterine  subinvolution  or  hyperplasia. 

To  attempt  the  radical  removal  of  these  vegetations  by  the  frequent 
application  of  milder  caustics  and  alteratives  would  be  a  mere  waste  of 
time. 

Experience  has  taught  me  that  simple  curetting,  even  though  thor- 
oughly done,  does  not  usually  suffice  to  permanently  prevent  the  re-forma- 
tion of  the  vegetations  and  the  return  of  the  menorrhagia.  Hence  I  have 
for  a  number  of  years  made  it  a  rule,  not  only  to  mop  the  uterine  cavity 
carefully  with  compound  tincture  of  iodine  (usually  the  cotton  plug  just 
described)  but  also  to  continue  these  applications  with  simple  tincture  of 
iodine  twice  a  week  until  at  least  two  menstrual  periods  have  been  normal, 
and  then  gi-adually  reduce  the  applications  to  one  a  week,  one  in  two 
weeks,  and  one  before  the  period,  until  I  could  feel  sure  of  a  permanent 
cure.  In  this  way  I  have  avoided  the  failures  which  I  have  several  times 
seen  in  cases  curetted  by  other  gynecologists,  who  had  neglected  the,  in 
my.  opinion,  indispensable  after-treatment. 

In  malignant  disease  of  the  endometrium,  which  occurs  chiefly  in  the 
form  of  diffuse  sarcomatous  degeneration  of  the  mucosa,  more  rarely  as 
true  carcinoma,  the  treatment  is,  first  to  thoroughly  remove  all  the  soft 
portions  of  the  growth  with  the  curette  (now  preferably  the  sharp  scoop, 
as  more  effectual),  and  then  aj)ply  as  strong  a  caustic  or  escharotic  as  the 
thickness  of  the  underlying  uterine  wall  seems  to  warrant.  Pure  chromic 
or  nitric  acid,  or  an  alcoholic  solution  of  bromine  (1 :  5)  are  generally  used 
for  this  purpose,  or  if  a  styptic  effect  is  also  desired,  the  solution  of  the 
persulphate  of  iron,  pure  or  mixed  with  equal  parts  of  glycerine.  A  very 
good  styptic,  although  in  no  sense  a  caustic,  is  the  saturated  solution  of 
resin  in  alcohol,  known  as  James'  styptic,  which  acts  by  covering  the  bleed- 
ing surface  with  a  film  of  resin  after  evaporation  of  the  alcohol. 

5.  Defective  Development  of  the  Uterus  •  Amenorrhea. — This  condition 
may  be  either  congenital,  the  uterus  never  having  attained  the  size  natural 
to  a  well-developed  woman  ;  or  acquired,  the  uterus  having  receded  from 
its  normal  state,  which  usually  occurs  as  the  result  of  excess  of  involution 
after  childbirth,  or  after  some  wasting  constitutional  disease  (typhoid  fever, 
tuberculosis,  cancer  in  other  organs).  Very  frequently  the  ovaries  partici- 
pate in  this  imperfect  development  or  atrophy. 

The  exudations  accompanying  and  often  persisting  after  local  or  gen- 
eral peritonitis  by  compressing  the  ovaries  and  interfering  with  normal 
ovulation  may  also  produce  amenorrhea.  Treatment  of  any  kind  is  usually 
of  little  avail  in  such  cases. 


230 


MINOR    GYNECOLOGICAL    MANIPULATIONS. 


Besides  such  general  remedies  and  measures  as  are  likely  to  stimulate 
tlie  whole  system,  and  thus  also  the  sexual  organs,  much  may  be  accom- 
pHshed  by  local  irritation  and  stimulation  by  means  of  hot  vaginal  injec- 
tions and  applications  to  the  endometrium.  The  agents  used  to  the 
uterine  cavity  are  merely  such  as  will  irritate  the  organ  and  attract  a 
greater  supj)ly  of  blood  to  it.  The  astringents  and  alterative-astringents, 
like  zinc,  copj)er,  iodine,  nitrate  of  silver,  would  not  be  indicated.  The 
chief  agent  used  is  carbohc  acid,  either  the  pure  concentrated  solution,  or 
Squibb's  impure  acid  (coal-tar  creasote),  and  its  counterpart,  pyroligneous 
acid,  diluted  with  an  equal  amount  of  glycerine.  This  must  be  apphed 
two  or  more  times  a  week,  most  thoroughly  during  the  week  just  preced- 
ing the  expected  menstrual  flow.     And  the  applications  must  be  continued 


Fig.  105 — Uterine  Electrode  as  Applied  for  Electrization  of  the  Uteras  (Beard  and  Rockwell). 

for  many  months  until  benefit  is  obtained,  or  the  futility  of  the  treatment 
recognized.  But  a  much  more  efficient  stimulus  to  the  undeveloped  or 
atrophic  uterus,  and  at  the  same  time  to  the  ovaries,  is  the  interrupted  or 
faradic  electric  current.  This  may  be  apphed  to  the  endometrium  by 
means  of  an  insulated  steel  sound,  the  other  electrode  being  placed  al- 
ternately on  the  abdomen  over  the  fundus  uteri  and  each  ovarian  region, 
or  over  the  sacrum  ;  the  strength  of  the  cun-ent  and  the  length  of  the 
sitting  will  depend  on  the  sensibihty  of  the  patient,  and  should  gradu- 
aUy  be  increased,  until  the  full  strength  of  the  battery  is  applied  and  the 
sitting  lasts  thirty  minutes.  As  with  the  medicinal  apx)lication,  so  should 
the  electricity  be  applied  most  thoroughly  immediately  preceding  a  men- 
strual epoch,  and  two  or  three  times  a  week  or  oftener  in  the  interval. 
In  obstinate  cases,  where  the  amenorrhea  depends  on  sluggish  circula- 


APPLICATlOlSrS  TO  MUCOUS  MEMBRANE  OF  UTERINE  CAVITY.    231 

tion  througli  a  subinvoluted  uterus  (as  in  fat,  plethoric  women),  tLe  con- 
stant current  may  be  used  tliree  or  more  times  a  week,  and  at  the  proper 
time  of  menstruation  the  faradic  current  in  inteiTupted  shocks  as  power- 
ful as  the  patient  will  bear  should  be  applied,  when  the  flow  may  at  once 
appear. 

In  some  cases  amenorrhea  does  not  depend  upon  deficient  development 
or  atrophy  of  the  uterus  or  ovaries,  but  rather  on  a  sluggish  pelvic  circu- 
lation and  a  want  of  innervation  of  the  ovaries.  Such  cases  are  usually 
those  of  women  who  either  have  had  children  or  are  steiile,  and  about 
their  thirtieth  year  rapidly  grow  stout  and  with  their  increasing  weight 
gradually  become  amenorrhoic.  In  such  women  the  nerve-force  formerly 
expended  on  their  ovaries  and  sexual  functions  appears  to  have  been  de- 
flected by  unknown  causes  to  their  assimilative  processes.  The  prognosis 
both  for  the  amenorrhea  and  sterility  is  generally  poor  in  these  cases, 
unless  the  nerve-force  can  be  returned  to  its  proper  direction  and  equal- 
ized thi'oughout  the  whole  system.  As  soon  as  we  reduce  the  flesh  of 
these  women  their  menstrual  flow  increases  and  there  is  a  chance  of  their 
conceiving.  But  how  to  reduce  the  flesh  is  the  problem  which  has  vexed 
many  a  practitioner.  The  Banting,  or  milk  cure,  Kissingen,  Saratoga, 
Kreuznach,  Carlsbad,  or  Marienbad  waters,  moderate  diet,  exercise,  chiefly 
horseback  riding,  and  general  and  local  massage — all  these  measures 
should  be  tried.  And  with  these  local  treatment  is  indispensable  ;  elec- 
tricity, carbolic  acid,  hot  injections  ;  and  if  the  uteiTis  is  hyperplastic,  as 
is  usually  the  case  with  parous  women  of  this  class,  frequent  moderate  de- 
pletion by  leeches  and  scarification  to  empty  the  ovei'loaded  vessels  and 
stimulate  the  circulation.  By  persisting  in  bringing  on  a  flow  of  blood 
from  the  uterus  every  four  weeks,  in  course  of  time  the  spontaneous  peri- 
odicity of  the  catamenia  may  often  be  restored. 

Agents  and  their  TJierapeutic  Uses. 

According  to  the  indication,  the  medicinal  agents  applied  to  the  endo- 
metrium are  divided  into  : 

1.  Caustics  :  Mild — nitrate  of  silver,    iodized  phenol,  carbolic  acid, 

pyroligneous  acid.  Strong — nitric  acid  (chemically  pure  ;  fum- 
ing is  not  necessary),  chromic  acid,  acid  nitrate  of  mercury, 
bromine,  chloride  of  zinc,  actual  cautery. 

2.  Astringents  and  Styptics  :  Sulphates  of  zinc,  copper,  alum,  nitrate 

of  silver,  tannin,  persulphate  or  perchloride  of  iron,  tincture  of 
iodine,  hydrastis,  eucalyptus,  resin,  pinus  Canadensis. 

3.  Alteratives  :  Iodine,  iodoform,  iodized  phenol,  galvanic  ciu'rent. 

4.  Stimulants  :  Carbolic  acid,  faradic  current. 

5.  Narcotics  :  Opium,  belladonna,  iodoform,  cocaine. 

6.  Disinfectants  :  Carbolic  and  salicylic  acid,  thymol,  permanganate 

of  potash. 

7.  Oxytocic  :  Ersot. 


232  MIISrOK    GYNECOLOGICAL    MANIPULATIO^-S. 

Caustics. — The  milder  caustics  are  used  chiefly  in  chronic  catarrhal 
conditions  of  the  endometrium  ;  the  strong  caustics,  when  it  is  desired  to 
produce  a  more  decided  impression,  or  form  a  slough,  as  in  hejuorrhage 
from  diffuse  hyperplasia  of  the  uterine  mucosa,  and  in  malignant  disease. 

The  actual  cautery  has  already  been  described  under  applications  to 
the  cervical  cavity.  Its  employment  in  the  cavity  of  the  uterus  proper  is 
too  dangerous  to  admit  of  its  being  recommended.  The  effect  and  extent 
of  the  cautery  cannot  well  be  regulated,  and  even  expert  operators  have 
done  mischief  with  it.  Thus  I  saw  one  gentleman,  an  expert  in  galvano- 
caustic  therapeutics,  perforate  the  fundus  uteri  with  the  galvanic  tip  (as 
shown  by  the  autopsy)  when  only  cauterization  of  the  cervical  canal  was 
intended.  The  only  way  in  which  the  actual  cautery  can  be  applied  with 
any  degree  of  safety  to  the  endometrium  is  by  means  of  the  platinum  tip 
of  a  galvano-cautery  battery,  which  is  introduced  cold  to  within  one-half 
inch  of  the  fundus,  the  current  then  turned  on  and  the  tip  immediately 
withdrawn. 

Astringents  and  Styptics. — These  agents  are  used  in  very  much  the 
same  class  of  cases  as  the  milder  caustics  ;  besides,  in  menorrhagia  or 
metrorrhagia,  whether  proceeding  from  local  or  general  causes.  In  chronic 
endometritis,  at  the  beginning  of  the  treatment,  the  best  local  remedies 
probably  are  :  the  nitrate  of  silver  (gr.  20  to  3  j.  to  the  ounce),  carbolic 
acid  (pure  or  equal  parts  with  glycerine),  iodized  phenol  (pure  in  aggra- 
vated cases).  When  the  superficial  film  produced  by  these  agents  has 
come  away  (in  from  three  to  five  days),  the  astringents  come  into  play,  and 
then  the  sulphates  of  zinc,  copper,  or  alum  (  3  j.  to  the  ounce,  or  saturated 
solution),  or  tannin  (pure  or  with  iodoform,  equal  parts),  persulphate  or 
perchloride  of  iron  (best  mixed  with  equal  parts  of  glycerine),  will  be  found 
more  beneficial  than  the  continuance  of  the  caustics.  Still,  a  repetition  of 
the  caustic  previously  used,  or  a  new  one  may  be  called  for,  if  a  trial  of 
one  or  more  of  these  astringents  proves  ineffectual  in  the  course  of  a  few 
weeks. 

It  should  be  particularly  remembered  that  chronic  corporeal  endo- 
metritis is  quite  as  intractable  a  disease  as  the  same  condition  in  the  cer- 
vical canal,  and  that  perseverance,  caution,  and  avoidance  of  all  preventable 
risks  on  the  part  of  the  physician,  and  patience  and  strict  attention  to 
directions  on  the  part  of  the  patient  are  requisite  to  a  successful  termina- 
tion of  the  treatment.  Further,  that  a  change  from  one  remedy  to  the 
other,  from  caustics  to  astringents,  and  back  to  caustics  again,  trying  dif- 
ferent strengths  of  the  same  agent,  and  occasionally  giving  the  patient  a 
week's  rest,  are  essential  points  in  the  treatment. 

If  the  patient  suffers  from  metrorrhagia  as  a  symptom  of  endometritis 
agents  should  be  chosen  for  intra-uterine  application  which  possess  a  styp- 
tic or  astringent  property  besides  their  caustic  effect.  Such  are  the  nitrate 
of  silver,  iodized  phenol,  and  tincture  of  iodine,  and  all  those  mentioned  in 
this  section.  The  application  of  carbolic  acid,  for  instance,  would  increase 
the  hemorrhage,  although  it  might  possibly  benefit  the  catarrh.  When  the 
metrorrhagia  is  the  only  symptom  for  which  the  application  is  made,  the 


APPLICATIONS  TO  MUCOUS  MEMBRANE  OF  UTERHSTE  CAVITY.     233 

astringent  indication  should  predominate  in  the  choice  of  the  remedy,  and 
the  stick  of  silver  nitrate,  or  saturated  solution  of  chloride  of  zinc,  or 
Churchill's  tincture  of  iodine,  or  persulphate  of  iron  and  glycerine,  or  tan- 
nin in  stick  with  glycerine,  or  alum,  zinc,  or  copper  pencils  may  be  intro- 
duced. Pure  nitric  acid  acts  as  an  excellent  hemostatic  in  a  different 
manner,  by  destroying  the  bleeding  vessels. 

The  resinous  agents  (fl.  extr.  hydrastis,  eucalyptus,  and  pinus  Cana- 
densis) act  chiefly  by  their  astringent  and  stimulant  projoerties,  but  are  too 
mild  to  be  useful  as  hemostatics.  The  mechanical  action  of  the  alcoholic 
solution  of  resin  as  a  styptic  has  already  been  referred  to. 

Alteratives. — Besides  acting  as  caustics  and  astringents,  the  iodized 
phenol  and  tincture  of  iodine  possess  a  local  alterative  property  which  is 
likewise  peculiar  to  another  iodine  compound,  iodoform.  Their  use  is  in- 
dicated in  chronic  endometritis  when  it  is  desired  to  promote  the  absor^D- 
tion  of  a  hyperplastic  mucous  membrane,  and  set  up  a  fresh  and  healthy 
action  in  place  of  the  subacute  or  chronic  inflammatory  condition.  In  this 
sense  these  alteratives  are  also  stimulants.  The  iodoform  is  also  very 
mildly  anesthetic.  Besides  stimulating  the  mucous  membrane,  alterative 
applications  to  the  endometrium  excite  a  subinvoluted  or  hyperplastic 


Fig.  106.— Cup  Electrode  for  Galvanization  of  Uterus  (Beard  and  Rockwell). 


uterus  to  contraction  and  to  absorption  of  its  pathological  constituents. 
This  they  do  both  by  local  stimulation  of  the  circulatory  and  absorbent 
apparatus,  and  through  the  general  system  after  their  absorption.  That 
agents  applied  to  the  endometrium  are  absorbed,  and  that  very  rapidly, 
is  proved  by  the  peculiar  taste  of  iodine,  carbolic  acid,  or  iodoform  ex- 
perienced in  the  mouth  of  the  patient  in  less  than  ten  minutes  after  the 
application. 

An  excellent  alterative  is  the  constant  galvanic  electric  cun-ent,  passed 
through  the  uterus  by  means  of  a  probe-shaped  electrode  introduced  into 
the  cervical  canal  with  a  cup  attached  into  which  the  cervix  fits.  (Fig.  lOG.) 
The  sponge  electrode  is  placed  over  the  abdomen  or  spine,  a  large  flat 
sponge  being  most  serviceable.  If  the  endometrium  jDroper  is  to  be  acted 
upon  (for  instance,  in  membranous  dysmenorrhea),  the  electrode  shown  in 
Fig.  105  may  be  employed.  A  metal  ball  or  olive,  covered  with  chamois 
leather  and  attached  to  a  long  insulated  stem,  is  a  very  convenient  electrode 
for  the  surface  of  the  cervix  and  the  vaginal  vault,  and  is  the  form  I  gener- 
ally use  in  galvanization  for  chronic  cellulitis,  peritonitis,  and  ovaritis,  the 
fiat  sponge  being  placed  either  over  the  abdomen,  sacrum,  or  hip,  the 
latter  when  sciatica  is  complained  of.  The  sittings  should  be  every  day 
or  every  other  day,  and  last  from  fiiteen  to  thii-ty  minutes.     The  alterative 


234:  MINOR    GYNECOLOGICAL    MANIPULATIONS. 

effect  is  exerted  not  only  on  the  mucous  membrane,  but  on  tlie  ■whole 
uterus,  and  is  accompanied  by  a  very  grateful  soothing  influence  on  the 
nerves.  I  have  greatly  benefited  inveterate  cases  of  areolar  hypei*plasia 
with  the  distressing  neuroses  recently  referred  to  by  a  persistent  use  of 
galvanism  thus  apphed.  I  have  recently  had  a  most  excellent  result  in 
a  case  of  hemicrania  (migraine)  and  sciatica  in  which  the  attacks  came  on 
weekly  or  oftener,  and  were  particularly  severe  at  the  menstrual  period, 
rendering  the  lady  a  confirmed  invalid  and  unable  to  take  part  in  any 
social  enjoyment.  Examination  revealed  a  complete  laceration  of  the 
cervix  (of  eighteen  years'  standing)  with  cicatrization  of  the  everted  sur- 
face, and  a  very  sensitive,  hard  nodule  of  plastic  exudation  extending  from 
the  right  angle  of  the  laceration  into  the  cellular  tissue.  Pressure  on 
this  sjjot  produced  intense  sciatica.  Vaginal,  and  later  intra-uterine  gal- 
vanization, three  to  six  sittings  a  week,  the  negative  pole  in  the  vagina, 
brought  about  a  complete  cure  of  the  neuralgia,  an  absolute  cessation  of 
the  vomiting,  and  a  disappearance  of  the  local  exudation. 

I  have  also  seen  decided  benefit  from  mild  intra-uterine  galvanization 
in  neuralgic  dysmenorrhea  which  had  resisted  dilatation  and  all  other  topi- 
cal measures. 

Stimulants. — The  stimulating  effect  of  carbolic  acid  and  electricity  on 
the  uterus  is  entirely  a  local  one.  It  is  intended  to  excite  the  gi'owth  of 
the  uterus  or  produce  a  flow  of  blood  from  it  by  u-ritating  the  organ  ;  and 
anything  that  accomplishes  this  object  is  indicated  precisely  in  proportion 
to  the  effect  it  produces,  and  the  absence  of  dangerous  reaction.  Thus 
the  frequent  introduction  of  the  sound,  the  dilatation  of  the  cervical  canal 
by  sponge-tents  introduced  at  inteiwals  of  one  to  four  weeks,  the  stimulus 
of  sexual  intercourse,  will  in  time  arouse  the  uterus  to  an  increase  of  size. 
For  the  development  of  the  ovaries  particularly,  the  interrupted  current 
is  most  effectual,  appUed  as  above  described.  This  treatment  should  be 
continued  for  months  or  years. 

Narcotics. — It  does  not  frequently  happen  that  any  of  the  narcotic 
agents  above  enumerated  require  to  be  introduced  into  the  uterine  cavity. 
If  so,  they  are  generally  emploj'ed  in  combination  with  some  agent  which 
is  likely  to  give  pain,  such  as  tannin,  ergot,  carbolic  acid.  The  narcotic  is 
then  generally  added  to  a  suppository  or  bougie  of  cocoa-butter  or  gela- 
tine. The  most  useful  narcotic  for  this  purpose  (if  it  can  be  so  called)  is 
iodoform.  A  solution  of  hydrochlorate  of  cocaine  introduced  on  an  appli- 
cator has  recently  been  employed  as  a  local  anesthetic,  but  the  exjDense  of 
the  drug  interferes  with  its  use  in  gynecological  practice. 

Disinfectants  are  seldom  used  in  the  undilated  uterine  cavity,  for  the 
reason  that  the  necessity  for  them  is  not  met  with  except  in  case  of  de- 
composing tumors,  or  after  oi^erations  for  the  removal  of  such,  or  after 
miscarriage  or  labor  at  term.  In  all  these  cases  the  cervical  canal  is 
either  spontaneously  patulous,  or  has  been  widely  dilated  by  artificial 
means.  The  disinfectant  is  then  introduced  in  more  or  less  diluted  solu- 
tion (as  stated  under  Vaginal  Injections)  by  means  of  the  same  injection- 
apparatus,  especial  care  being  taken  that  the  fluid  escapes  as  rapidly  as  it 


APPLICATIOISrS  TO  MUCOUS  MEMBRANE  OF  UTERINE  CAVITY.    235 

enters.  The  patient  sbould  lie  witli  hips  not  higher  than  the  shoulders, 
the  stream  should  be  thrown  in  from  a  fountain  syringe,  and  the  nozzle 
of  the  syringe  be  devoid  of  a  central  aperture.  If  these  precautions  are 
observed,  no  danger  need  be  anticipated  from  such  injections.  Their  use, 
of  course,  will  be  indicated  so  long  as  the  condition  which  called  for  them 
— the  presence  of  decomposing  matter  in  the  uterine  cavity — exists. 

Oxytocics. — The  only  medicinal  agent  which  is  introduced  into  the 
uterine  cavity  for  the  purpose  of  producing  contractions  of  that  organ  is 
ei'got.  It  has  been  used  by  Emmet  and  others  with  the  object  of  promot- 
ing the  extrusion  and  expulsion  of  submucous  or  polypoid  fibrous  tumors 
of  the  uterus,  being  apjDlied  in  the  form  of  suppositories  of  cocoa-butter 
containing  ten  or  fifteen  grains  of  Squibb's  aqueous  extract  of  ergot,  and 
has  been  found  very  efficient  in  this  manner.  I  believe,  however,  that  the 
same  object  can  be  attained  quite  as  effectually  and  with  less  inconvenience 
to  patient  and  physician  by  rectal  suppositories  of  the  same,  or  slightly 
less,  amount.  The  faradic  current  may  also  be  employed  as  an  oxytocic. 
To  many  of  the  agents  mentioned,  chiefly  tincture  of  iodine,  persulphate 
and  perchloride  of  iron,  tannin,  pinus  Canadensis,  the  addition  of  glycerine 
in  equal  parts,  or  less  amount  if  it  is  not  desired  to  dilute  the  aj^plication 
so  much,  is  very  beneficial.  The  firm  coagula  produced  by  the  iron  solu- 
tions, for  instance,  are  prevented  by  the  glycerine,  and  their  accumulation 
in  the  uterine  cavity  is  thus  avoided. 

The  agents  most  in  use  in  ordinary  intra-uterine  medication  (for 
chronic  endometritis,  metroiThagia,  subinvolution,  atrophy,  etc.)  are  the 
tincture  of  iodine  (simple  and  compound),  pure  and  imjjure  carbolic  acid, 
solution  of  nitrate  of  silver,  nitric  acid.  The  first  three,  either  j^ure  or 
mixed  with  glycerine,  are  almost  the  only  ones  used  by  me. 

Tlie  time  and  frequency  of  making  intra-uterine  apjMcations  depends 
entirely  iipon  the  indication.  In  serious  cases,  of  course,  no  time  should 
be  lost,  and  alarming  or  long-existing  hemorrhage  or  malignant  disease 
should  be  attacked  at  once  by  the  remedy  appi'opriate  to  the  case.  Many 
a  time  have  I  applied  the  tincture  of  iodine  to  a  bleeding  endometrium, 
feeling  that  the  first  indication  was  to  arrest  the  hemorrhage,  and  have 
then,  at  my  leisure,  removed  its  cause. 

As  a  rule,  intra-uterine  applications  should  be  made  in  the  intermen- 
strual period,  the  nearer  the  last  period  [i.e.,  the  more  imj)i'essible  the  en- 
dometrium after  the  superficial  exfoliation  of  its  epithelium)  the  better. 
Thus,  alterative  applications  are  most  effective  soon  after  the  period. 
Stimulant  applications,  however,  which  are  made  to  bring  on  the  men- 
strual flow,  meet  with  the  best  results  if  made  immediately  before  the  ex- 
pected appearance  of  that  phenomenon.  Also,  when  an  immediate  styp- 
tic effect  is  desired,  i.e.,  when  the  intention  is  to  diminish  an  expected 
menstrual  flow,  a  styptic  application  immediately  before  the  jDeriod  is  in- 
dicated. On  the  other  hand,  styptic,  astringent,  caustic,  and  stimulant 
agents  are  in  order  after  the  flow  when  a  lasting  impression  is  desired. 
The  frequency  of  intra-uterine  applications  must  be  regulated  by  the  se- 
verity of  the  disease  and  the  tolerance  of  the  patient.     Some  patients  will 


236  MINOR    GYNECOLOGICAL    MANIPULATIOISTS. 

easily  stand  tbi'ee  applications  a  week,  others  react  severely  on  one.  It 
is,  therefore,  always  wise  to  begin  with  a  mild  application  until  the  sensi- 
tiveness of  that  particular  patient  has  been  ascertained. 

Caustics  should,  as  a  rule,  be  repeated  not  oftener  than  once  a  week  ; 
the  strong  agents  not  until  the  slough  has  disappeared,  and  then  only  if 
the  pathological  condition  appears  so  little  improved  as  to  decidedly  call 
for  a  fresh  cauterization. 

Astringents  will  probably  need  to  be  applied  at  least  twice  a  week. 
Styptics  only  as  often  as  the  hemorrhage  returns  ;  or  if  it  continues,  every 
day  until  it  ceases.  Alteratives  generally  twice  a  week.  Stimulants  the 
same,  or  oftener.  Of  narcotics  and  disinfectants  it  is  only  necessary  to 
say  that  their  application  is  usually  but  temporary,  and  depends  entirely 
on  momentary  indications. 

The  sole  oxytocic,  ergot,  will  be  used  in  utero  only  so  long  as  it  either 
produces  the  desired  result  or  shows  its  inefficiency,  probably  not  longer 
than  a  few  days. 

The  strength  of  intra-uterine  applications  has  already  been  referred  to 
in  discussing  the  various  agents.  It  is  impossible  to  make  fixed  rules  as  to 
the  strength  of  an  application  for  each  individual  case.  General  directions 
having  been  given,  the  practitioner  must  learn  by  experience  how  strong 
solutions  or  combinations  a  patient  needs  or  can  bear.  The  rule  to  begin 
with  milder  applications  and  to  gradually  increase  their  strength  as  the  en- 
durance of  the  patient  becomes  known  has  already  been  pointed  out.  As 
a  disease  improves,  the  applications  should  be  made  less  and  less  frequently, 
and  their  strength  be  gradually  reduced,  or  the  agent  changed  for  a  milder 
one,  until  the  disease  is  entirely  cured. 

Conditions  Necessary  for  Intra-uterine  Applications. 

An  indispensable  condition  to  the  proper  application  of  medicinal  agents 
to  the  uterine  cavity  is  that  the  cervical  canal  and  its  up^Dcr  and  lower  ori- 
fice be  sufficiently  patent  to  permit  the  easy  passage  of  the  instrument 
carrying  the  remedy.  A  uterine  canal  which  permits  the  free  passage  of 
the  Simpson  sound  will  usually,  unless  very  tortuous  or  rugous  (flexions, 
endotrachelitis),  admit  any  of  the  ordinary  applicators  wrapped  with  a  thin 
film  of  cotton.  Other  methods  of  application  (hereafter  to  be  described  in 
detail)  will  require  preparatory  dilatation  in  pro]3ortion  to  the  method. 
The  more  thorough  the  application  is  to  be  and  the  more  powerful  the 
agent,  the  more  sloughing  and  discharge  is  likely  to  follow  it,  and  the 
larger  must  the  cervical  canal  be,  in  order  that  the  sound  parts  be  not 
touched  when  the  application  is  made  and  there  be  no  obstruction  to  the 
discharge.  When  frequent  apphcations  are  required,  when  a  powerful 
caustic  like  nitric  acid,  iodized  phenol,  or  chromic  acid  is  to  be  used  (as  is 
often  the  case  in  hyperplastic  or  villous  endometritis,  and  always  in  malig- 
nant disease)  the  cervical  canal  should  be  previously  dilated  by  artificial 
means.  A  sponge,  laminaria,  or  tupelo-tent  will  accomplish  this  within 
twelve  hours.     It  should  be  remembered,  however,  that  in  a  very  large  pro- 


METHODS    OF    MAKING    INTRA-UTEEINE    APPLICATIONS.       237 

portion  of  the  cases  in  which  intra-uterine  apphcations  are  required  (endo- 
metritis, metrorrhagia)  the  constant  flow  of  either  mucus  or  blood  in  itself 
dilates  the  canal  and  renders  it  patulous,  and  that  therefore  artificial  dila- 
tation may  often  be  disjDensed  with. 

When  disinfectant  applications  to  the  endometrium  are  required  the 
conditions  which  call  for  them  (sloughing  or  removal  of  fibroids,  or  ma- 
lignant growths)  will  also  have  produced  a  sufficient  dilatation,  so  that  the 
fluid,  which  in  these  cases  is  best  introduced  by  injection,  can  readily  enter 
and  escape. 

A  precaution  to  be  observed  with  all  applications  to  the  endometrium 
is  to  prevent  the  agent  from  escaping  from  the  external  os  and  burning 
the  vagina  and  perhaps  the  vulva.  This  is  likely  to  occur  as  well  with 
solid  agents,  which  melt,  as  with  originally  fluid  remedies.  It  can  be  pre- 
vented by  placing  a  tampon  over  the  os,  or  plugging  the  cervical  canal 
with  cotton. 

Other  special  conditions  and  precautions  will  be  referred  to  under  each 
separate  method. 


Methods  of  Making  Intra-uteeike  Applications. 

Medicinal  agents  may  be  introduced  into  the  uterine  cavity  by  various 
methods  and  in  numerous  forms.  The  following  list  comprises  all  in  pres- 
ent use,  the  most  efficient  and  practical  being  named  first : 

1.  On  applicators  (probe-shaped  rods)  wrapped  with  cotton. 

2.  Through  an  applicator  syringe. 

3.  By  injection. 

4.  In  soluble  tents  or  bougies. 

5.  As  ointments  (with  fluids  and  powders). 

6.  On  a  caustic -holder. 

The  nature  of  the  application  indicates  that,  by  Methods  1,  2,  and  3, 
only  fluids  can  be  introduced  ;  by  the  other  methods,  solids  and  powders. 
I  might  have  divided  the  applications  into  those  of  fluids,  and  those  of 
solid  agents  ;  but  thought  it  would  be  more  practical  to  classify  the 
methods  according  to  their  efficiency,  since  some  of  the  agents  (iodine, 
nitrate  of  silver)  are  applied  both  in  the  solid  form  (in  tents  and  stick)  and 
in  solution. 

1.  On  Aiyplicatori^. — The  appUcation  of  fluids  to  the  endometrium  dif- 
fers in  execution  and  facility  accordingly  as  the  cervical  canal  has  its  nor- 
mal dimensions,  or  has  been  dilated  by  natural  or  artificial  means. 

a.  Through  the  Undilated  Germcal  Canal. — The  instruments  emjDloyed 
to  carry  fluids  into  the  uterine  cavity  are  sound-  or  probe-shaped  rods 
of  metal  or  hard  rubbei\  The  vehicle  containing  the  fluid  is  cotton, 
preferably  absorbent  cotton,  which  is  wound  about  the  uterine  end  of 
the  appHcator,  at  a  thickness  adequate  to  absorb  sufficient  fluid,  and  still 


238  MINOR    GYNECOLOGICAL    MANIPULATIONS. 

not  to  interfere  ■with  the  passage  of  the  appHcator.  AjjpHcators  are  either 
flat  or  round,  and  if  the  latter,  gently  tapering  to  the  point.  The  metal 
applicators  are  made  of  silver,  aluminium,  platinum,  even  gold,  for  the 
praxis  aurea,  or  of  copper,  nickel-plated,  for  hospital  use.  The  objection 
to  the  plated  applicators  is  that  they  requh-e  frequent  replating,  and  are 
very  easily  twisted  and  ruined,  but  their  cheapness  fully  counterbalances 
this  advantage.  A  greater  objection,  in  my  mind,  to  all  soft  metal  appli- 
cators is  their  extreme  flexibility,  which  in  a  but  slightly  patent  or  rugous 
canal  results  in  their  bending  at  every  obstruction,  and  interfering  with 
introduction.  Mere  curvature  of  the  canal  is  no  obstacle,  since  the  appH- 
cator can,  and  should,  be  bent  to  conform  to  the  previously  ascertained 
curve.  Inflexible  metal  applicators  are  not  in  use  in  this  country,  hard 
rubber  having  taken  their  place.  I,  for  my  part,  prefer  applicators  made 
of  hard  rubber,  shaped  liked  Simpson's  sound,  but  much  thinner,  per- 
fectly smooth,  and  almost  in-elastic.  Some  of  these  applicators  are 
made  with  a  bulbous  tij),  but  I  decidedly  object  to  this,  as  it  renders  the 
removal  of  the  moist  cotton  after  the  application  a  difficult  matter.  A 
very  good  hard-rubber  apphcator  with  flat  uterine  portion  is  made  by 
Shepard  &  Dudley,  of  New  York.  A  straight,  tapering,  and  exceedingly 
elastic  rubber  applicator,  sold  by  many  instrument-makers,  does  not  meet 
with  my  approval,  as  it  twists  and  bends  at  every  angle  or  rugosity  of  the 
uterine  canal,  and  is  exceedingly  difficult  of  introduction,  except  in  a 
widely  patent  passage.  In  some  applicators  the  uterine  two  and  one  half 
inches  are  slightly  roughened,  so  as  to  retain  the  cotton.  This  is  not  at 
all  necessary,  and  occasions  decided  annoyance  when  the  moist  cotton  is  to 
be  removed.  The  flexible  metal  aj)plicators  first  recommended  by  Emmet, 
and  sold  under  his  name,  had  a  wire-spring  slide  for  the  purpose  of  shp- 
ping  off  the  cotton.  But  this  slide  interferes  with  the  handling  of  the 
instrument,  and,  if  the  cotton  is  pi'operly  wrapped,  is  not  needed. 

A  certain  knack  is  required  to  wrap  an  applicator  properly  with  cot- 
ton, so  that  the  cotton  envelope  will  not  be  too  thick,  nor  too  tightly 
wound,  or  so  loosely  as  to  be  slid  up  from  the  point  when  the  apphcator 
is  passed  through  the  internal  os  (the  narrow  spot  of  the  canal),  or  be 
left  in  the  cavity  when  the  applicator  is  withdrawal.  The  physician 
should  practise  wrapping  his  applicators  until  he  has  acquired  the  neces- 
sary skill,  as  a  trained  nurse  may  not  always  be  at  hand.  The  applicator 
is  seized  in  the  right  hand,  its  end  moistened,  and  a  tJwi  film  of  absorbent 
cotton,  about  three  inches  long  by  two  inches  wide,  is  laid  on  the  palmar 
surface  of  the  four  fingers  of  the  left  hand ;  the  applicator  is  then  seized 
between  the  thumb  and  first  two  fingers  of  the  right  hand,  and  placed 
lengthwise  on  the  film  of  cotton,  close  to  its  left  boi-der.  By  then  rotating 
the  applicator  with  the  right  hand,  the  cotton  is  twisted  around  its  uterine 
end,  and  evenly  and  smoothly  arranged  by  the  thumb  and  first  two  fingers 
of  the  left  hand.  Care  should  be  taken  not  to  let  the  twisted  cotton  pro- 
ject beyond  the  end  of  the  applicator,  else  this  loose  bit  will  double  over 
and  prevent  the  passage  of  the  instrument.  The  end  of  the  applicator 
should  be  smoothly  and  tightly  covered,  so  that  there  is  no  danger  of  the 


METHODS    OF    MAKING    INTRA-UTERINE    APPLICATIONS.       239 

bare  point  being  pushed  through  it,  and  the  cotton  shpped  up  the  aj)ph- 
cator  as  its  tip  passes  the  internal  os.  If  this  should  occur,  and  force 
were  used,  under  the  imj)ression  that  the  length  of  cotton-covering  still 
outside  of  the  external  os  shows  that  the  point  has  not  reached  the  fun- 
dus, it  is  evident  that  the  uterus  might  be  seriously  injured.  It  is  well  to 
wrap  not  less  than  two  and  a  half,  and  not  more  than  three  inches  of 
the  tip  of  the  applicator  with  cotton,  in  order  to  be  able  to  see,  by  the  end 
of  the  cotton  being  at  the  external  os,  that  the  fundus  has  been  reached, 
and  also  to  be  able  to  seize  the  projecting  bit  of  cotton  with  the  forceps, 
in  case  it  should  chance  to  be  left  behind  in  the  uterus.  The  fundus  will, 
of  course,  also  be  recognized  by  the  touch. 

The  cotton  should  be  wrapped  so  tightly,  especially  near  the  tip,  that 
it  wiU  not  slip  and  become  wrinkled  as  it  is  passed  through  the  cervical 
canal ;  and  again  not  so  tightly  that  it  cannot  absorb  readily  and  be  easily 
slipped  off  after  its  withdrawal  from  the  uterus.  If  a  flat  metal  applica- 
tor is  used  the  uterine  end  should  be  dipped  in  oil  or  vaseline  before 
wrapping  it,  which  will  greatly  facilitate  the  removal  of  the  cotton.  This 
is  readily  done  by  seizing  it  between  the  blades  of  the  dressing-forceps 
and  slipping  it  off,  care  being  taken  to  grasp  the  cotton- wrapped  portion 
at  least  near  its  middle  in  order  not  to  push  the  cotton  all  together  in  a 
ball,  when  its  removal  will  be  very  difficult.  The  cotton  wrapping  should 
correspond  in  thickness  to  the  size  of  the  uterine  canal.  In  the  undQated 
state,  no  more  than  a  thin  film  of  cotton  can  be  passed. 


Fig.  107.  -  Hard-rubber  Applicator  used  by  P.  F.  M. 

Manner  of  Using  the  Applicator. — It  is  almost  needless  to  say  that  the 
application  must  be  made  through  a  speculum.  If  the  cervical  canal  is 
normally  patent  and  there  is  no  tortuosity  or  flexion,  a  large  cylindrical 
or  plurivalve  will  answer,  precisely  as  for  the  passage  of  the  sound.  But 
an  application  is  more  difficult  in  that  the  cotton  film,  no  matter  how 
smoothly  rolled,  will  be  likely  to  catch  in  the  cervical  canal  and  the  cervix 
be  pushed  back  and  the  application  fail.  It  is,  therefore,  generally  neces- 
sary to  steady  the  cervix,  and  draw  down  and  straighten  the  uterus  by  a 
tenaculum  hooked  into  its  anterior  lip.  The  direction  and  Avidth  of  the 
uterine  canal  should  have  been  ascertained  before  making  the  application 
by  passing  the  sound  after  the  speculum  has  been  introduced.  I  prefer 
the  sound  to  the  probe,  as  it  gives  a  better  indication  of  the  width  of  the 
canal.  If  the  sound  cannot  be  passed  through  the  round  or  valvular  spec- 
ulum, it  is  evident  that  an  application  will  fail ;  and  the  Sims  speculum 
should  be  at  once  inserted  in  the  position  and  according  to  the  rules  al- 
ready described. 

The  following  rules  apply  to  an  application  through  any  speculum :  The 
cervix  having  been  exposed,  the  anterior  lip  is  seized  with  a  tenaculum, 
the  uterus  gently  drawn  down  and  straightened,  and  the  sound  passed  to 


240  MINOR    GYNECOLOGICAL    MANIPULATIONS. 

the  fundus.  The  dh-ection  and  width  of  the  uterine  canal  thus  ascertained 
should  be  carefully  remembered,  as  it  is  exceedingly  awkward  to  find  the 
point  of  the  applicator  arrested  at  some  spot  within  the  canal,  and  the 
fluid  expressed  in  futile  attempts  to  reach  the  fundus.  The  operator  then 
seizes  an  apphcator  (of  which  several  should  be  at  hand  wrapped  with  cot- 
ton) and  passes  it  dry  to  the  fundus  in  order  to  absorb  and  remove  the 
uterine  secretions,  or  any  blood  which  may  have  escaped  since  the  sou.nd- 
ing.  If  the  oozing  (chiefly  of  blood)  is  rapid,  it  is  well  to  leave  one  appli- 
cator in  the  uterus  to  absorb  it  until  the  medicated  rod  can  be  prepared 
and  introduced.  If  the  secretion  is  very  thick  and  tenacious,  it  should  be 
removed  with  the  uterine  spdnge,  or  an  applicator  dipped  in  a  solution  of 
bichromate  of  potash  (1  :  8)  or  pure  carboHc  acid  may  succeed  in  detach- 
ing it.  Several  applicators  may  thus  need  to  be  passed  before  the  canal  is 
clear  and  dry. 

This  removal  of  tenacious  cervical  mucus  is  often  exceedingly  difficult, 
and  various  devices  have  been  adopted  by  different  gynecologists  to  effect 
this  purpose.  Dr.  Thomas  prefers  conical  bits  of  dry  sponge  j^assed  into 
the  cervix  on  a  dressing-forceps;  Dr.  Lusk  uses  an  instrument  like  a 
double  blunt  Avire  cm-ette,  introduced  from  England ;  others  succeed  with 
an  applicator  wrajD^Ded  with  absorbent  cotton  ;  I  often  find  it  necessary  to 
empty  the  follicles  by  scraping  the  ceiwical  cavity  Avith  Thomas'  blunt  cu- 
rette before  I  can  clear  the  passage  of  its  secretions.  An  absolute  cleansing 
of  the  cervical  and  uterine  cavities  is  necessary  to  the  effectual  apj)lication 
of  remedies. 

In  moistening  the  applicator  in  the  fluid,  care  should  be  taken  not  to 
saturate  it  too  profusely,  or  the  greater  part  of  the  fluid  will  be  squeezed 
out  and  flow  on  the  vagina  before  the  uterine  cavity  is  reached.  The  bottle 
containing  the  agent  should  be  placed  conveniently  at  the  right  hand,  the 
soaked  applicator  standing  in  it  ready  for  the  hand  of  the  operator.  The 
uterine  cavity  having  been  moj)ped  out,  the  dry  ajDplicator  is  quickly  re- 
moved and  dropped  into  the  basin,  and  the  medicated  applicator  seized 
and  passed  rapidly  in  the  ascertanied  direction  to  the  fundus.  If  there  is 
any  obstacle  to  its  immediate  passage,  that  attempt  may  be  put  down  as  a 
failure,  since  the  irritation  of  the  internal  os  by  the  agent  results  in  its 
contraction  and  closure  to  the  point  of  the  applicator.  The  latter  may 
then  as  well  be  withdrawn,  and  the  attempt  repeated  after  a  short  inter- 
val. If  the  canal  is  not  very  pervious  and  the  agent  is  particularly  irri- 
tant or  caustic  (like  pure  carbolic  acid  or  iodized  phenol)  it  may  be 
advisable  to  protect  the  cervix  and  vagina  by  placing  a  layer  of  cotton  un- 
derneath it. 

The  applicator,  having  been  safely  passed  to  the  fundus,  may  be  allowed 
to  remain  a  few  moments,  especially  if  it  be  soaked  in  iodine  with  a  hemo- 
static purpose  ;  or,  if  an  imtant  or  caustic  effect  is  desired,  it  may  be 
di'awn  back  and  forth  several  times  and  then  removed.  If  it  is  grasped  by 
the  uterus,  no  force  should  be  used,  for  in  a  few  moments  the  contraction 
will  cease,  and  the  applicator  is  then  easily  withdrawn.  If  a  very  decided 
effect  is  intended,  or  if  hemorrhage  stOl  continues,  the  application  may  be 


METHODS    OF    MAKING    INTRA-UTEEINE    APPLICATIONS.       241 


repeated  with  a  fresli  applicator.  When  the  applicator  has  been  with- 
drawn, the  tenaculum  is  detached,  all  excess  of  fluid  is  mopped  up,  the 
vagina  dried,  and  a  flat  tampon  soaked  in  glycerine  having  been  placed 
over  the  cervix,  the  speculum  is  removed. 

b.  Through  the  Dilated  Cervical  Canal. — The  canal  may  be  dilated 
either  as  a  result  of  the  condition 
which  calls  for  the  application  (endo- 
metritis, metrorrhagia),  or  it  may  not 
have  contracted  after  a  shortly  j)re- 
ceding  miscarriage  or  labor,  or  it  may 
be  naturally  patulous  on  account  of 
many  labors  and  subinvolution,  or 
finally,  it  may  have  been  dilated  by 
artificial  means.  It  is  self-evident 
that  the  more  pervious  and  the  wider 
the  uterine  canal  the  easier  the  in- 
troduction of  sound  or  applicator. 
When  a  very  thorough  ap]3hcatiou  is 
intended,  and  eveiy  portion  of  the 
endometrium  is  to  be  touched,  it  is 
advisable  to  dilate  the  uterus  before 
making  the  application.  It  is  not 
always  necessary  to  do  this  with 
slowly  dilating  measures  (tents),  but 
rapid  forcible  dilatation  may  suffice. 
I  frequently  introduce  the  two-blad- 
ed steel  dilator  shown  in  Fig.  120, 
and  stretch  the  whole  cervical  canal 
with  its  two  orifices  to  the  width  of 
half  an  inch,  and  then  find  a  previ- 
ously impossible  or  difficult  apjDlica- 
tion  an  easy  matter.  Or  I  introduce 
the  applicator  into  the  uterine  canal 
between  the  branches  of  the  dilator 
when  they  are  separated. 

When  the  uterine  canal  is  mod- 
erately dilated,  I  either  use  the  stiff 
whalebone  applicator,  above  de- 
scribed, wrapping  more  cotton  about 
it,  or  I  employ  the  thicker  applicator  '^\'^^''''  ^^^^^  AppUcator 
with  a  slide  introduced  by  Sims.  This 
applicator  is  stiffer  than  the  one  already  recommended,  and  the  most  con- 
venient instrument  when  a  thorough  application  is  to  be  made.  When  a 
more  permanent  effect  is  desired,  I  slide  the  cotton  off  (the  left  hand  press- 
ing the  slide  against  the  cervix  while  the  other  withdraws  the  rod),  and 
leave  it  in  the  uterine  cavity  for  twenty-four  or  forty-eight  hours.  I  then 
either  remove  it  myself  or  let  the  patient  do  so  by  a  thread  attached  to  it. 


Fig.  108.— Sims'  Hard- 


FlG.  10!).— Sim.s'  Slide 
Applicator  Wrapped  with 
Cotton  for  Saturation, 
and  to  be  Left  in  the  Ute- 
rine Cavity  (P.  F.  M.). 


242  MINOR    GYNECOLOGICAL    MANIPULATIONS. 

This  maneuvre  is  specially  useful  in  case  of  hemorrhage,  when  the  strong 
tincture  of  iodine  or  the  solution  of  the  persulphate  of  iron  and  glycerine 
are  the  articles  used  as  a  styptic.  In  subinvolution  and  areolar  hyperplasia 
a  more  decided  stimulant  and  absorbent  effect  may  be  thus  obtained.  In 
hemorrhage  the  cotton  itself  acts  as  an  intra-uterine  tampon.  If  not  re- 
moved, the  cotton  will  in  two  or  three  days  become  loosened  in  the 
uterine  cavity,  there  will  be  a  somewhat  offensive  discharge,  and  the 
cotton  will  either  be  washed  out  by  this  discharge  or  be  expelled  by  ute- 
rine contractions.  Occasionally,  however,  the  retained  cotton  will  produce 
so  much  irritation,  local  (hemorrhage)  and  constitutional  (febrile  reac- 
tion), as  to  require  immediate  removal  as  soon  as  these  symptoms  present 
themselves.  While  it  may  be  beneficial  in  hemorrhage  and  diffuse  hyper- 
plastic endometritis  to  allow  the  cotton  to  slough  away,  it  is  generally  ad- 
visable to  attach  a  stout  thread  to  the  plug  (as  seen  in  the  diagram)  by 
which  the  patient  herself  can  remove  it  whenever  necessary.  In  no  case 
should  the  plug  be  allowed  to  remain  in  the  uterine  cavity  longer  than 
three  days.  Even  this  period  would  be  inadmissible  did  not  the  iodine  in 
which  the  plug  was  soaked  prevent  its  early  decomposition.  When  the 
uterine  canal  is  widely  pervious,  as  after  labor  or  miscarriage,  or  dilatation 
by  tents,  I  generally  make  the  application  by  means  of  the  ordinary  straight 
whalebone  or  hard-rubber  screw-stick  (see  Fig.  87),  the  screw  end  of  which 


Fig.  110.— Straight  Slide  Applicator  (P.  F.  M.).     The  cotton  plug  in  this  cut  should  be  much  longer. 

is  wrapped  tightly  with  as  large  a  roll  of  cotton  as  will  pass  soaked  in  the 
agent,  and  the  cervix  being  steadied  with  the  tenaculum,  is  passed  straight 
to  the  fundus  and  twisted  about  there  until  the  whole  cavity  is  thoroughly 
mopped.  I  have  thus  frequently  applied  iodine,  carbolic  acid,  iodized  phe- 
nol, and  even  pure  nitric  acid.  If  the  external  os  is  sufficiently  patulous 
and  its  lips  are  separated  by  the  tenaculum,  very  little  fluid  will  touch  the 
outer  portion  of  the  cervix  and  escape  into  the  vagina.  Of  course,  the 
usual  precautions  of  first  mopping  out  the  cavity  and  protecting  the  vagina 
with  cotton  should  be  observed,  and  an  excess  of  fluid  should  be  squeezed 
out  of  the  cotton.     The  glycerine  tampon  is  of  course  placed  over  the  cervix. 

When  I  wish  to  leave  a  larger  plug  of  cotton  in  such  a  well-dilated 
uterus,  as  a  tamj)on  chiefly,  I  use  such  a  straight  hard-rubber  stick  with  a 
metal  slide,  but  smooth  all  its  length,  so  as  to  shde  the  cotton  off  easily. 

When  an  application  of  so  powerful  an  agent  as  nitric  acid  is  made  to 
the  endometrium  it  is  done  because  a  milder  remedy  is  not  thought  suffi- 
cient ;  the  effect  desired  is,  therefore,  as  thorough  a  one  as  is  consistent 
with  safety.  The  conditions  in  which  nitric  acid  is  employed  are  chiefly 
polypoid  vegetations  of  the  endometrium  (endometritis  villosa,  polyposa, 
hyperplastica,  hemorrhagica),  the  main  symptom  of  which  is  hemorrhage, 
malignant  degeneration  (sarcoma)  of  the  uterine  mucosa  ;  and  membra- 
nous dysmenorrhea,  in  the  latter  of  which  it  is  desired  to  destroy  the  mu- 


METHODS    OF    MAKING    INTRA-UTERINE    APPLICATIONS.        243 

cous  membrane  down  to  tlie  muscular  coat,  and  substitute  cicatricial  tissue, 
or  at  least  remove  so  much  of  the  hyperplastic  membrane  as  to  insure  the 
growth  of  a  new,  presumably  more  healthy,  coat.  The  acid  must  there- 
fore be  employed  thoroughly,  and  no  fear  need  be  entertained  that  an  ex- 
cess will  create  too  deep  an  eschar.  It  is  not  diffusible  like  caustic  potash, . 
and  rapidly  produces  an  albuminate  with  the  tissues  which  prevents  it 
from  entering  deeper  than  to  a  certain  limited  extent  into  the  mucous 
membrane.  The  shock  and  reaction  from  nitric  acid  applied  to  the  endo- 
metrium, when  used  in  this  manner  through  a  widely  dilated  cervical 
canal  from  which  the  slough  and  secretions  can  readily  escape,  is  no 
greater  than  after  iodine  or  carboUc  acid ;  and  the  benefit,  in  the  proper 
cases,  is  most  decided. 

The  advantages  of  these  applications  on  cotton-wrapped  applicators  are 
the  ease,  rapidity,  painlessness,  with  which  they  are  performed,  and  the 
absence  of  the  necessity  for  previous  dilatation  of  the  uterine  canal. 

The  disadvantages,  however,  are  quite  sufficient  to  induce  us  to  seek 
other  and  better  means.  These  disadvantages  may  really  be  summed  up 
in  one  word — inefficiency.  In  the  cases  where  a  widely  dilated  cervical 
canal  permits  the  easy,  unhindered  introduction  of  a  large  cotton  swab, 
the  application  can  be  made  thoroughly,  and  the  result  mil  be  proportion- 
ately rapid  and  good.  But  when  the  canal  is  narrow — that  is,  when  it  has 
the  normal  width  and  merely  admits  the  sound — it  is  unavoidable  that  by 
far  the  largest  portion  of  the  fluid  in  which  the  applicator  was  dipped 
must  be  pressed  out  and  trickle  out  of  the  os,  and  what  little  reaches  the 
uterine  cavity  proper  is  so  neutralized  by  its  contact  with  the  secretions 
of  the  cervix  as  to  be  almost  inert.  In  the  vast  majority  of  cases  with 
normal  cervical  canals,  I  really  believe  that  the  effect  of  the  agent  is  ex- 
pended entirely  on  the  mucous  lining  of  the  cervical  canal,  and  that  the 
endometrium  proper  is  touched  merely  by  the  albuminous  coating  of  the 
applicator.  "Where  an  irritant  effect  is  desired,  this  may  be  of  little  con- 
sequence, for  the  applicator  itself  drawn  back  and  forth  irritates  the  endo- 
metrium ;  but  when  a  decidedly  caustic  or  astringent  influence  is  intended, 
the  result  generally  fails  to  meet  the  expectations. 

To  remedy  this  objection  various  contrivances  have  been  proposed  by 
which  it  was  designed  to  protect  the  cervical  canal  from  the  remedy,  as 
well  as  the  remedy  from  the  cervical  canal,  and  keep  the  applicator  free 
until  it  had  passed  the  internal  os.  The  manner  of  accomphshing  this 
was  by  means  of  a  tube  which  was  introduced  into  the  cervical  canal  up  to 
or  through  the  internal  os,  and  through  which  the  applicator  (or  stylet,  as 
it  is  then  called)  is  passed.  Such  devices  are  those  of  Wylie,  of  New  York, 
Lombe  Atthill,  of  Dublin,  Woodbury,  of  Washington,  D.  C,  Peaslee,  and 
numerous  others. 

These  canula3,  or  cervical  specula,  are  made  of  metal  (silver  or  pla- 
tinum), hard  rubber,  or  glass  (W^oodbury's).  They  are  introduced  into 
the  cervical  canal  up  to  (and  should  be  through)  the  internal  os;  the 
cotton-wrapped  stylet,  which  has  been  soaked  in  the  agent  and  withdrawn 
into  the  canula,  is  then  pushed  forward  until  it  touches  the  fundus.     Or 


244  MIlSrOR    GYNECOLOGICAL    MANTPULATIOlSrS. 

the  canula  may  have  been  inserted  alone,  and  the  stylet  is  then  thrust 
through  it.     Canula  and  stylet  are  then  removed  together. 

The  principle  of  these  instruments  is  very  good,  but,  as  with  many 
other  contrivances,  is  not  confirmed  by  practice.  If  the  cervical  canal 
and  internal  os  are  sufficiently  patulous,  no  doubt  the  canula  can  easily  be 
passed  through  the  latter,  and  will  answer  its  purpose  perfectly.  But  in 
these  cases  we  can,  perhaps,  succeed  quite  as  well  without  the  canula,  al- 
though doubtless  all  contact  with  the  cervix  is  obviated  by  it.  But  in  the 
very  class  of  cases  in  which  such  a  protector  is  most  needed,  in  the  normal 
cervical  canal  with  narrow  internal  orifice,  perhaps  with  an  angle  of  flexion 
at  that  spot,  the  cervical  protector  is  too  large  to  pass  through  or  even  to 
the  internal  os.  To  be  of  any  service  the  canula  must  have  at  least  the 
diameter  of  one-eighth  of  an  inch  inside  measurement,  and  this  is  pre- 
cisely the  diameter  of  the  bulb  at  the  tip  of  Simpson's  sound.  Now  take 
the  thickness  of  the  walls  of  the  canula,  and  add  a  little  lee-way  for  the 
stylet  to  play,  and  we  have  a  canula  of  at  least  one-fourth  inch  diameter, 
which  is  the  least  size  through  which  a  cotton-wrapped  stylet  can  be 
thrust  without  expressing  the  fluid.  And  a  normal  internal  os  seldom 
measures  one-fourth  inch  in  diameter.  Besides,  the  sharp  border  of  the 
canula  catches  at  the  internal  os  and  can  be  introduced  no  farther.  Un- 
less the  canula  passes  the*  internal  os,  the  stylet  will  almost  inevitably 
catch  at  that  spot,  and  the  application  prove  a  failure.  I  speak  from  an 
extended  experience  in  making  this  criticism  on  these  applicators  with 
cervical  protectors,  and  much  prefer  to  make  an  application  between  the 
expanded  branches  of  a  steel  dilator. 

When  the  cervical  canal  is  dilated,  however,  and  the  canula  can  pass 
the  internal  os  it  is  a  great  convenience.  And  I  notice  that  the  inventors 
of  these  instruments  speak  of  their  employment  in  precisely  such  cases. 
For  the  application  of  nitric  acid,  they  are  then  particularly  useful,  and 
Atthill  employs  his  applicator  almost  entirely  for  this  agent.  Before  ap- 
plying nitric  acid  or  iodized  phenol  to  the  endometrium,  I  should  always 
dilate  the  cervical  canal  thoroughly  and  consider  the  whole  procedure  in 
the  light  of  an  operation  ;  the  gravity  of  the  diseases  requiring  such  pow- 
erful remedies  certainly  justifies  that  precaution.  An  ordinary  glass  tube, 
with  an  inside  diameter  of  half  an  inch,  will  then  answer  every  purjpose, 
and  it  need  not  even  be  curved  when  the  cervical  canal  is  so  widely  dilated. 

A  cheap  and,  compared  with  the  instruments  above  described,  equally 
eflicient  contrivance  is  that  of  an  ordinary  No.  12  elastic  catheter,  with  the 
end  cut  off  square  ;  the  mandrin  is  then  used  precisely  like  the  stylet  in 
the  other  applicators.  I  believe  it  was  devised  by  Dr.  James  E.  Chadwick, 
of  Boston.  If  it  were  safe  to  inject  fluid  into  the  undilated  cavity  of  the 
uterus,  this  would  be  a  very  easy  w^ay  out  of  the  dilemma.  But,  as  I  shall 
explain  in  detail,  hereaftei',  intra-uterine  injections,  even  with  all  proper 
precautions,  are  so  dangerous  as  to  have  been  almost  abandoned  by  the 
profession.  With  the  view  of  combining  the  efficiency  of  injections  with 
the  safety  of  applications,  several  gynecologists  have  hit  upon  a  plan,  which 
I  shall  now  describe  under  the  name  of  the 


METHODS    OF    MAKING    INTEA-UTERINE    APPLICATIONS.        245 

2.  Applicator-syringe. — Several  years  ago,  having  by  experience  become 
fully  alive  to  the  objections  against  the  ordinary  uterine  applications,  I 
chanced  to  meet^with  Buttles'  uterine  syringe,  and  it  occurred  to  me  that  a 
very  good  way  to  avoid  the  expression  and  albumination  of  the  fluid  in 
the  cervical  canal  would  be  to  first  fill  the  sja-inge  with  the  application 
fluid,  then  wrap  absorbent  cotton  about  the  uterine  portion  (precisely  as 
described  for  the  applicator),  introduce  it,  and  gently  exjoress  the  fluid. 
The  dry  cotton  having  thus  been  introduced  into  the  uterine  cavity,  the 
slow  expression  of  the  fluid  would  gradually  saturate  the  cotton,  and  the 


Pig.  111. — Applicator-syringe  (P.  F.  M.). 

agent  thus  in  its  undiluted  condition  come  in  contact  with  the  endome- 
trium. I  at  once  put  this  idea  into  execution,  and  found  that  it  answered 
perfectly  ;  the  very  slender  nozzle  of  the  syringe  (which  is  of  hard  rubber 
and  holds  about  one-half  a  drachm  of  fluid)  when  wrapped  by  a  thin  film 
of  cotton,  presented  no  obstacle  to  its  introduction  through  almost  any 
normal  cervical  canal ;  the  thin  film  of  cotton  allowed  the  fluid  to  ooze 
through  it  gradually  (as  can  be  seen  on  trying  the  experiment  outside  of 
the  body),  and  the  shock  of  the  rapid  injection  of  fluid  was  thus  avoided. 
Nothing  but  the  usual  slight  sensation  of  warmth  in  the  hypogastric  re- 
gion, occasionally  moderate  pain,  was  experienced.  As  soon  as  the  cotton 
was  saturated,  the  fluid  escaped  from  the  external  os  ;  and  this  was  a  sign 
to  cease  the  injection.  I  made  the  application  usually  through  a  Sims 
speculum,  but  frequently  through  a  large  cylindrical  or  bivalve,  and  found 
no  difficulty  in  passing  the  slender  cotton-wrapped  syringe  tip  to  the  fun- 
dus uteri.     Only  in  three  or  four  instances  did  I  witness  more  than  the 


Fig.  112. — Applicator-syringe,  Filled  and  Wrapped  with.  Cotton,  Ready  for  Use  (P.  F.  M.). 


above-mentioned  slight  hypogastric  pain.  I  have  applied  through  this 
syringe  only  the  tincture  of  iodine  (simple  and  compound),  the  pure  and 
impure  carbolic  acid,  the  nitrate  of  silver  (  3  j.  to  3J.),  and  pure  nitric 
acid.  Each  of  these,  the  nitric  acid,  the  impure  carbolic,  the  silver-nitrate 
solution,  and  the  tincture  of  iodine  produced  a  decided  constitutional 
shock  in  one  instance,  which  required  the  hypodermic  use  of  moriDhine, 
alcoholic  stimulants,  and  a  rest  of  several  hours.  No  further  unpleasant 
consequences  ensued. 

In  order,  however,  to  avoid  even  this  rare  shock,  I  adopted  the  plan  of 


246  MINOR    GYNECOLOGICAL    MANIPULATIONS. 

propelling  the  piston  of  tlie  syringe  merely  by  turning  it,  as  one  does  a 
screw,  and  withdrawing  it  as  soon  as  I  noticed  fluid  escaping  from  the  ex- 
ternal OS.  In  this  manner  any  sudden  forcing  of  the  fluid  through  the 
cotton  into  the  uterine  cavity  was  avoided,  and  an  excess  at  once  relieved. 
I  have  employed  this  method  many  hundreds  of  times,  and  am  convinced 
that  it  is  the  most  efficient,  convenient,  and  safe  method  of  making  intra- 
uteiine  applications.  Even  the  application  of  nitric  acid,  which  was  only 
once  followed  by  ^hock,  was  performed  thi'ough  an  undilated  uterine  canal. 
Had  previous  dilatation  been  practised,  I  am  confident  no  reaction  would 
have  occurred,  and  subsequent  experience  confirms  this  view. 

After  I  had  used  this  method  for  all  cases  in  which  the  cervical  canal 
was  not  sufficiently  patulous  to  permit  the  unobstructed  passage  of  the 
aj)phcator,  I  heard  accidentally  that  Drs.  Lawson  and  Lente,  of  New  York, 
had  proposed  a  similar  device  several  years  previously.  On  looking  the 
matter  up,  I  found  that  these  gentlemen  had  recommended  the  ordinary 
h}'podermic  sjTinge  with  a  long  flexible  uterine  tube  of  silver  for  the  same 
purpose.  The  advantage  of  these  silver  tubes  is  that  they  can  be  bent  to 
conform  to  the  curve  of  the  uteiine  canal ;  but  the  objection  to  them  is 
that  they  are  more  likely  to  become  clogged  by  the  corrosion  of  the  metal 
from  the  nitric  acid  or  iodine,  which  are  among  the  jDrincipal  agents  used 
for  intra-uterine  ai^plications.  The  nitrate  of  silver  will  of  com'se  tarnish 
ptu'e  silver  if  the  solution  is  at  all  strong. 

In  all  these  apphcator-syringes  the  final  two  and  a  half  inches  of  the 
uterine  end  of  the  tube  are  made  very  slender  (the  uterine  portion  of 
Buttles'  hard-rubber  syringe  is  a  fine  jDiece  of  workmanship),  and  are  per- 
forated with  numerous  small  holes.  The  expansion  of  the  tube  two  and  a 
half  inches  from  the  tip  shows  the  limit  of  the  normal  uterine  canal.  This 
application  may  be  made  without  a  speculum,  the  syringe  being  intro- 
duced like  the  sound  on  the  finger ;  but  the  oozing  of  fluid  fi'om  the  os 
requires  a  tampon,  which  cannot  readily  be  placed  without  a  speculum. 

Care  shovild  be  taken  to  wrap  the  cotton  sufliciently  tight  about  the 
syringe,  or  it  may  be  left  in  the  uterine  cavity  when  the  nozzle  is  with- 
drawn. But  it  should  not  be  -wrapped  so  tightly  as  to  interfere  with  its 
proper  saturation  with  fluid  from  the  syi'inge.  If  the  cotton  should  slip 
from  the  nozzle  and  remain  in  the  uterine  cavity,  the  dressing-forceps 
shoivld  be  introduced  and  the  cotton  plug  sought  for  until  found  and 
withdrawn.  If  particular  difficulty  is  experienced  in  accomplishing  this, 
it  may  be  preferable  to  leave  the  expulsion  of  the  cotton  to  the  uterus, 
which  will  generally  contract  upon  and  express  it  in  a  few  days.  Or  it 
will  be  washed  out  b}'  the  ordinary  uterine  discharge.  Should  it  not  be 
noticed  in  the  secretions,  or  in  the  water  escaping  during  the  usual  vagi- 
nal injections,  the  patient  having  been  instructed  to  watch  for  it,  a  fresh 
attemjDt  may  be  made  to  remove  it  with  forceps,  or  the  uterus  may  be 
rapidly  dilated  with  steel-branched  dilators,  and  the  cotton  removed.  Obri- 
ously,  it  would  be  unsafe  to  allow  a  foreign  body  of  the  putrescent  tendency 
of  cotton  to  remain  in  the  uterine  cavity  for  an  indefinite  j)eriod  ;  besides  the 
risk  of  septic  infection,  a  hemorrhage  would  be  excited  by  it  sooner  or  later. 


METHODS    OP    MAKING   INTEA-UTERINE    APPLICATIONS.        247 

Tamponade  of  the  uterine  cavity,  ali-eacly  briefly  referred  to.  From  the 
description  of  the  use  and  objects  of  the  Sims  sHde-appKcator,  it  is  quite 
evident  that  the  cotton  sKpped  off  from  it,  and  left  in  the  uterine  cavity, 
will  act  not  only  by  its  medicinal  ingredients,  but  also  by  direct  pressure 
on  the  endometrium.  The  plug  thus  introduced,  therefore,  acts  as  a 
styptic,  which  is  the  object  desired  in  tamponing  the  uterine  cavity.  If, 
therefore,  a  woman  is  bleeding  from  her  uterus,  the  latter  is  not  at  aU,  or 
but  moderately,  dilated,  and  it  is  desired  to  arrest  the  hemorrhage  at  once 
and  with  absolute  certainty,  the  very  best  means  to  accomjplish  this  is  to 
introduce  as  large  a  cotton  plug  as  possible  up  to  the  fundus  on  a  Sims 
slide-applicator,  slip  it  off,  and  leave  it  in  the  uterus  for  twenty-four  hours 
or  longer.  The  effect  of  the  tampon  is  greatly  increased  by  saturating  it 
in  strong  tincture  of  iodine  as  described,  which  besides  guards  it  from  de- 
composition, or  a  solution  of  persulphate  of  iron  and  glycerine,  equal  parts, 
will  be  found  serviceable.  This,  then,  is  the  simplest,  quickest,  and  most 
efficient  method  of  arresting  uterine  hemorrhage  by  tamponing  the  cavity 
of  the  organ.  A  vaginal  tampon  applied  through  a  Sims  speculum  (as  de- 
scribed under  Tampons)  should  generally  be  introduced,  and  both  these 
applications  repeated  in  twenty-four  to  forty-eight  hours.  The  vaginal 
tamjion  may  be  renewed  in  twenty -four  hours,  the  uterine  not  until  forty- 


FlG.  113. — Slide-applicator,  Wrapped  with  Thick  Cotton  Plug,  for  Tamponade  of  Utem?  (P.  F.  M.). 

eight  hours  or  longer,  if  the  hemorrhage  has  not  returned.  It  can  be  re- 
moved by  the  string  attached  (see  Fig.  113),  or  it  may  have  been  left  so 
long  as  to  project  from  the  external  os,  and  be  easily  removable  by  forceps. 
It  may  not  require  repetition  if  the  hemorrhage  has  ceased.  It  is  advis- 
able to  combine  the  influence  of  rest  and  internal  hemostatics  with  the 
local  measures,  in  order  to  remove  the  cause  of  the  flow  and  prevent  its 
repetition. 

When  the  uterine  canal  is  widely  dilated,  as  after  removal  of  a  fibroid 
polj-pus  or  submucous  or  interstitial  fibroid,  or  occasionally  for  persistent 
hemorrhage  after  abortion,  the  uterine  cavity  is  tamponed  more  after  the 
manner  described  for  the  vagina,  viz.,  by  passing  small  flat  jDledgets,  or 
little  balls  of  cotton,  soaked  in  carbolized  alum,  or  weak  chloride  of  zinc 
solution,  and  squeezed  dry,  into  the  cavity  with  long  forceps,  and  packing 
them  tight  until  the  cavity  is  filled  ;  a  vaginal  tampon  then  keeps  the 
uterine  column  in  place.  The  uterine  pledgets  are  removed,  by  screwing 
the  tampon-extractor  into  the  cotton,  and  removing  them  one  by  one. 
Both  the  introduction  and  removal  of  the  tampons  are  best  performed 
through  Sims'  speculum. 

3.  Injection. — I  shall  not  devote  much  space  to  the  discussion  of  the 
injection  of  fluids  into  the  undilated  utei-ine  cavity,  for  the  reason  that  I 
think  they  are  not  to  be  recommended.     Many  articles  have  been  written 


248  MnsroR  gynecological  manipulation-s. 

on  the  subject,  the  majority  of  the  writers  agreeing  that  uterine  injections 
are  an  efficient  remedy  in  catarrhal  and  hemoiThagic  conditions  of  the  en- 
dometrium, but  accompanied  by  a  degree  of  danger  which  should  lead  us 
to  be  extremely  cautious  in  using  them.  The  late  Dr.  J.  C.  Nott,  of  New 
York,  was  one  of  the  last  to  write  an  elaborate  and  widely  quoted  article 
on  the  subject,  in  which  he  maintained  that  intra-uterine  injections  are 
safe  and  justifiable  if  the  uterine  canal  is  thoroughly  dilated  and  there  is 
no  obstruction  to  the  free  escape  of  the  injection  fluid,  and  subsequent  se- 
cretions. This  is  at  present  the  opinion  of  the  large  majority  of  careful 
gynecologists  all  over  the  world  ;  but  it  is  safe  to  say  that,  the  uterine 
cavity  having  been  once  thoroughly  dilated,  it  is  still  less  dangerous,  while 
quite  as  efficient,  to  mop  it  out  with  an  impregnated  cotton  swab  (such  as 
the  screw-stick  repeatedly  spoken  of). 

The  dangers  from  intra-uterine  injections  do  not  lie  so  much  in  the 
strength  or  nature  of  the  chemical  agents  used,  although  of  course  the 
more  powerful  the  agent,  the  stronger  its  local  and  general  impression  ; 
but  rather  in  the  shock  imparted  to  the  nerv^ous  system  by  the  sudden 
dilatation  of  the  uterine  cavity  by  the  injected  fluid,  in  the  danger  of  peri- 
tonitis from  the  uterine  ii'ritation,  and  finally  in  the  possibility  of  the  fluid 
passing  through  the  Fallopian  tubes  into  the  peritoneal  cavity,  and  there 
setting  up  a  violent  peritonitis.  The  two  first  accidents,  shock  and  peri- 
tonitis, are  the  most  Hkely  to  occur  ;  but  the  entrance  of  fluid  into  the 
tubes  has  in  several  instances  been  verified  at  the  autops}'.  To  prevent 
the  shock  and  the  passage  of  the  tubes,  the  inevitable  rule  of  previously 
dilating  the  uterine  canal  has  been  laid  down,  supposing  that  the  ready 
escape  of  the  fluid  would  prevent  these  accidents.  Notwithstanding,  sev- 
eral of  the  sixteen  deaths  which  I  find  reported  as  having  occurred  in  con- 
sequence of  intra-uterine  injections,  took  place  after  the  necessity  for 
this  precaution  was  recognized,  and  under  the  hands  of  experienced  and 
competent  operators.  Numerous  cases  of  merely  temporary  shock,  col- 
lapse, uterine  cohc,  and  of  peritonitis,  followed  by  recovery,  which  have 
doubtless  occurred  as  a  direct  result  of  these  injections,  have  not  been  re- 
ported, but  their  occuiTcnce  has  doubtless  led  all  cautious  gynecologists  to 
limit  intra-uterine  injections,  even  with  a  dilated  canal,  to  those  cases  in  xvhich 
ordinary  applications  failed,  or  the  removal  of  intra-uterine  tumors  or  an  im- 
inature  ovum  required  the  cleansing  of  the  widely  dilated  cavity  by  antiseptic 
irrigation.  In  the  latter  class  of  cases  I  have  frequently  washed  out  the 
uterine  cavity  with  both  hot  and  cold  water,  propelled  either  by  a  David- 
son or  fountain  sjTinge,  and  have  never  seen  the  slightest  evil  result  there- 
from. I  have  several  times  seen  quite  severe  shock  and  uterine  pain  follow 
applications  with  the  applicator-syringe,  as  just  described,  when  the  fluid 
was  forced  too  rapidly  through  the  cotton,  so  as  almost  to  resemble  an 
injection,  and  have  no  desire  to  repeat  such  an  experiment.  In  any  case 
where  it  is  justifiable  to  run  such  a  risk  as  an  intra-uterine  injection  carries 
with  it,  it  is  certainly  worth  the  while  to  dilate  the  cavity  thoroughly  and 
make  the  application  by  a  swab.  For  the  benefit  of  those  cases  in  which 
repeated  powerful  applications  fail  (such  as  obstinate  chronic  endometritis, 


METHODS    OF    MAKING    INTRA-UTERIJSTE    APPLICATIONS.       249 

and  hemorrliage  from  flaccidity  of  the  mucosa),  and  an  excess  of  the  agent 
seems  called  for,  I  will  point  out  briefly  the  manner  of  injecting  the  uterine 
cavity  :  the  width  of  the  uterine  canal  being  at  least  that  of  the  little 
finger,  the  cervix  is  exposed  tlu-ough  a  large  plurivalve  speculum  ;  the 
uterus  drawn  down  and  straightened  by  a  tenaculum  in  the  anterior  lip,  so 
as  to  efface  any  angle  at  the  internal  os.  The  syringe  is  then  filled  with 
the  fluid  (tincture  of  iodine,  carbolic  acid,  iodized  phenol,  solution  of  the 
persulphate  or  perchloride  of  iron  with  equal  parts  of  glycerine)  and  intro- 
duced to  the  fundus.  Withdrawing  it  then  about  one- fourth  of  an  inch, 
the  fluid  is  \3ery  gently  and  slowly  expressed,  drop  by  drop,  by  tm-ning  the 
piston-screw,  not  pushing  it,  until  from  five  to  ten  minims  are  expressed, 
according  to  the  size  of  the  cavity.  This  expression  should  occupy  several 
minutes.  The  patient  should  be  kept  in  bed,  and  under  opium  for  at  least 
twenty-four  hours. 

The  syringe  may  be  either  that  of  Buttles  or  Lente,  or  if  a  larger 
tube  is  desired,  that  of  Bumstead  is  a  good  instrument.  Or  the  glass  tube 
with  rubber  bulb  of  Woodbury  or  White  may  be  used.  Dr.  Nott  used  a 
double-current  catheter,  through  which  he  injected  several  ounces  or 
more  of  medicated  Avater,  beginning  with  plain  water  to  test  the  uterus. 
His  catheter  is  almost  identical  with  that  of  Skene  for  the  bladder. 

It  is  better  to  make  all  intra-uterine  injections  on  the  back,  rather  than 
in  the  semiprone  position,  because  the  escape  of  the  fluid  is  facihtated  in 
the  dorsal  position,  and  there  is  less  likelihood  of  the  fluid  passing  into 
the  Fallopian  tubes. 

The  frequency  of  strong  intra-uterine  injections  will  conform  entirely 
to  the  necessities  of  the  case  and  the  general  rules  given  under  Applica- 
tions. 

A  use  of  intra-uterine  injections  which  cannot  be  classed  under  the 
same  category  as  those  treated  of  here,  is  for  the  cure  of  sterility  by  in- 
jecting a  small  quantity  of  fresh  semen  into  the  uterus.  The  same  pre- 
cautions should  be  observed  as  in  therapeutic  injections,  so  far  as  gentle- 
ness and  slowness  of  expression  of  the  fluid  is  concerned  ;  but  it  is  not 
customary  to  dilate  the  uterus  beforehand.  Still,  if  the  canal  were  ab- 
normally narrow,  the  injection  even  of  semen  would  be  quite  as  hazardous 
as  of  a  chemical  agent.  For,  even  a  few  drops  of  pure  water  or  glycerine 
have  produced  severe  uterine  coHc.  This  method  of  artificial  im23regTia- 
tion  can  scarcely  be  said  to  have  established  itself  as  a  recognized  practice. 

4.  Medicated  Tents  or  Bougies. — With  the  view  of  avoiding  the  expres- 
sion of  the  agent  while  it  is  passed  through  the  cervical  canal  and  of 
escaping  the  dangers  inherent  to  uterine  injections ;  with  the  object,  there- 
fore, of  combining  efficiency,  safety,  and  ease  of  application,  and  of  avoid- 
ing the  tedious  and  always  somewhat  hazardous  preliminary  dilatation 
of  the  uterine  canal,  the  device  was  adopted,  years  ago,  of  incorporating 
the  medicines  in  some  soluble  but  temporarily  solid  vehicle,  to  which  a 
pencil-shape  was  given,  and  which  was  introduced  into  the  uterine  cavity 
and  allowed  to  melt  there.  The  vehicle  may  be  either  cocoa-butter,  gum- 
tragacanth,  gum-arabic,  paraffine,  or  gelatine.     Tannin  powder  is  the  only 


250  MINOK    GYNECOLOGICAL    MAISTIPULATIOIS'S. 

substance  which  can  be  simply  rubbed  up  with  glycerine  and  rolled  out 
to  any  thickness  desired  on  a  porcelain  tablet ;  it  hardens  in  the  air,  but 
does  not  readily  dissolve  in  the  uterine  cavity.  .Cocoa-butter  makes  a 
very  good  vehicle  for  suppositories,  but  it  is  too  fragile  for  pencils  so  thin 
as  these  for  the  uterus  require  to  be,  and  it  has,  therefore,  been  abandoned 
for  this  purpose,  Gum-tragacanth  and  gum-arabic  powder  make  elegant, 
slender  pencils,  but  they  become  so  hard  as  to  readily  injure  the  endome- 
trium and,  what  is  quite  as  important,  quoad  therapiam,  not  to  melt,  and 
therefore  prove  inert.  This  last  objection  applies  to  paraffine,  and  untU 
recently  also  to  gelatine.  But  within  the  past  few  years  experiments  in 
the  manufacture  of  gelatine  bougies  have  been  made  by  various  chemists 
of  New  York  and  elsewhere,  which  have  resulted  in  the  production  of 
an  exceedingly  efficient  article.  The  best  pencils  are  made  by  Joseph 
Fleischer,  a  druggist  of  New  York,  whom  I  have  already  mentioned  when 
speaking  of  vaginal  suppositories,  Parke  Davis  &  Co.,  of  Detroit,  and 
Charles  L.  Mitchell,  of  Philadelphia.  To  be  efficient  they  must  be  and  re- 
main soft  and  perfectly  flexible  ;  if  they  are  in  the  least  degree  hard  they 
fail  to  melt  in  the  utenis,  and  not  only  miss  their  purpose,  but  act  as  an 
irritant  and  excite  uterine  cohc.  A  soft  bougie  is  sure  to  be  melted  and 
absorbed  within  twelve  hours,  a  hard,  brittle  bougie  never.  If  they  are  to 
be  kept  any  length  of  time  and  in  a  warm  room,  it  is  best  to  preserve  them 
vprapped  up  in  waxed  paper  or  tinfoil,  to  prevent  absorption  of  moisture  ; 
but  some  of  my  iodoform  bougies,  esj)ecially,  have  retained  their  flexibiUty 
for  a  year  or  more  simply  kept  in  a  pasteboard  box. 


Fig.  114. — Tube  for  introducing  medicated  bougie.s  into  the  uterus  (P.  F.  M.). 

These  bougies  may  be  inserted  by  pushing  them  into  the  uterine 
cavity  through  a  speculum  with  the  dressing-forceps.  I  have  tried  this, 
but  found  that  the  smooth  pencils  would  shp  out  of  the  cervix  as  soon  as 
the  forceps  were  withdi'awn,  unless  they  were  pushed  beyond  the  internal 
OS,  which  required  the  deep  introduction  of  the  forceps  and  often  resulted 
in  the  removal  of  the  tent  with  the  forceps.  I  thought  some  kind  of  tube 
would  be  serviceable,  and  on  inquiry  at  Mr.  Schmidt's,  the  instniment- 
maker,  found  an  instrument  devised  by  Dr.  Barker,  for  the  introduction  of 
ointment  into  the  uterus  which  seemed  to  answer  the  purpose.  I  soon 
found  that  in  order  to  introduce  the  tube  and  expel  the  tents  with  one 
hand  I  needed  a  hold  on  the  handle  of  the  tube  for  thumb  and  two  fingers, 
and  consequently  had  the  instrument  shown  in  Fig.  114  constructed,  which 
answers  the  pui-pose  admirably.  The  tube  is  of  hard  rubber,  slightly  bent 
to  permit  its  easy  passage  to  the  internal  os.  The  instrument  can  be  intro- 
duced without  a  speculum,  or  through  a  large  tubular,  or  bivalve,  or  a  Sims 
speculum.  I  prefer  to  use  it  through  a  speculum  in  order  to  place  a  tam- 
pon over  the  os  afterward.     Before  exposing  the  cervix  through  the  Sims, 


METHODS    OF    MAKING    USTTRA-UTERINE    APPLICATIO^STS.       251 

I  place  the  bougie  in  the  tube,  push  it  forward  toward  the  uterine  end, 
and  then,  seizing  the  instrument  in  my  right  hand,  with  the  thumb  in  the 
ring  and  the  first  two  fingers  grasping  the  tube  at  the  broad  flange,  I  in- 
sert the  end  of  the  tube  into  the  cervical  canal  and  push  it  forward  as  far 
as  it  will  go.  Holding  it  steadily  in  the  cervical  canal,  I  push  forward  the 
piston  and  do  not  withdraw  the  tube  until  the  piston  is  jDushed  home.  I 
can  then  be  certain  that  the  tent  has  been  forced  through  the  internal  os 
into  the  uterine  cavity.  If  I  were  to  withdraw  the  tube  as  I  push  the  pis- 
ton forward,  the  tent  would  probably  be  but  partially  inserted.  The 
length  of  the  tent  is  made  to  correspond  to  that  of  the  uterine  cavity,  and 
its  pliability  prevents  injury  to  the  endometrium.  In  order  to  prevent  the 
dissolved  tent  from  escaping  from  the  external  os  and  burning  the  vagina 
and  vulva,  and  also  to  insure  its  full  effect  on  the  endometrium,  I  am  in 
the  habit  of  introducing  a  cotton  plug  into  the  cervix  with  Sims'  slide-ap- 
plicator. This  the  patient  removes  by  the  attached  string  on  the  following 
day,  and  then  uses  the  common  hot  or  cleansing  vaginal  injection.  The 
tents  are  generally  introduced  in  the  office,  and  the  patients  allowed  to  go 
about  their  usual  avocations.  Usually  one  bougie  suffices  for  each  treat- 
ment ;  but  if  the  uterine  cavity  is  much  dilated,  or  a  particularly  strong  ef- 
fect is  desired,  two  may  be  inserted  at  the  same  sitting.  To  do  this,  both 
are  passed  into  the  tube  at  once,  one  after  the  other,  and  the  first  tent 
having  been  deposited  in  the  uterine  cavity,  as  seen  by  the  length  of  piston 
still  exposed,  the  point  of  the  tube  is  turned  slightly  to  one  side,  and  the 
second  tent  placed  beside  the  first. 

I  have  introduced  these  pencils  many  times  and  have  never  seen  more 
than  very  slight  suprapubic  burning  follow.  In  no  case  was  either  the  in- 
troduction or  the  after-result  painful  or  productive  of  unpleasant  conse- 
quences. Some  of  the  gynecologists  who  have  used  them  speak  of  uterine 
colic  following  them,  but  I  have  not  seen  it  in  my  practice.  The  tents 
may  be  introduced  every  other  day,  or  twice  a  week,  as  the  case  requires. 

The  remedies  likely  to  be  useful  in  the  uterine  cavity,  the  amount  in 
each  bougie,  and  the  therapeutical  action,  are  given  in  the  following  list. 
Other  combinations  are  supphed  by  the  manufacturers,  but  those  given 
answer  nearly  every  pui-pose. 

Iodine,  gr.  v.  to  x.  ]  alterative. 

Iodine  comp.,  gr.  v.  to  x.  f  absorbent. 

Iodine,  and  carbolic  acid,  aa  gr.  v. — alterative  and  caustic. 

Iodoform,  gr.  v.  to  x.— alterative  and  anesthetic. 

Iodoform  and  tannin,  gr,  v.  gr.  iij.  j 

Iodoform  and  alum,  aa  gr.  v.  V  alterative  and  astringent. 

Sulph.  zinc  and  iodoform,  aii  gr.  v.  ) 

Sulphate  zinc,  gr.  v.  to  x.       ) 

Hydrastis  Canadensis,  gr.  x.  >  astringent. 

Chloride  zinc,  gr.  ss.  to  j.      ) 

Of  the  tents  contained  in  the  list  I  have  used  only  those  containing 
iodine,  iodoform,  carboHc  acid,  alum,  sulphate  of  zinc,  hydrastis  Canadensis, 
and  the  combinations  of  two  or  more  of  these  drugs.     Those  of  iodine. 


252  MINOE    GYNECOLOGICAL    MANIPULATIOlSrS. 

iodine  and  carbolic  acid,  iodoform,  and  iodoform  and  alum,  I  have  found 
most  serviceable.  Narcotic  agents  are  omitted  from  the  list,  as  they  act 
better  per  rectum. 

As  regards  the  efficiency  of  these  medicated  tents,  I  think  that  for  a 
gradual  effect,  an  effect  produced  to  a  certain  degree,  by  absorption  of 
their  ingredients,  they  excel  fluid  applications.  For  a  direct  stj'ptic 
effect,  however,  they  are  far  inferior  to  the  uterine  plug  soaked  in  tincture 
of  iodine  and  left  in  utero.  Therefore,  when  a  rapid,  sharp  effect,  either 
for  hemostasis  or  with  an  irritant  object,  is  intended,  the  introduction  of 
fluids  on  cotton-wrapped  apphcators  is  preferable.  For  subinvolution, 
hyperplasia,  and  chronic  endometritis  the  tents  are  superior. 

For  many  years  it  was  the  custom  here  and  abroad  to  introduce  the 
solid  stick  of  nitrate  of  silver,  or  of  equal  parts  of  nitrate  of  silver  and 
nitrate  of  potash,  into  the  uterine  cavity  and  di'op  it  there  to  melt  at  its 
own  leisure.  I  have  seen  many  such  sticks  of  the  nitrate  pushed  into  the 
uterus  with  the  "uterine  pistol "  (an  instrument  resembling  my  bougie- 
tube)  for  endometritis  or  "  chronic  metritis"  in  Braun's  clinic  in  Vienna, 
and  as  many  women  writhing  and  groaning  with  uterine  colic  for  an  hour 
or  more  afterward.  It  probably  was  efficient  treatment — it  certainly  was 
painful  enough  to  do  good  ;  but  I  think  it  was  rather  too  dangerous  to 
be  justifiable  as  a  routine  joractice.  I  have  already  expressed  my  opinion 
of  the  solid  nitrate  of  silver  as  an  application  to  the  uterus,  and  am 
glad  to  say  that  with  us  it  is  no  longer  practised.  Solid  sticks  of  the 
sulphates  of  copper  and  zinc,  fused  and  cast  in  thin  moulds,  have  been 
introduced  in  the  same  manner  ;  but  I,  for  my  part,  am  afraid  of  these 
strong  applications  in  solid  form.  They  may  cure,  but  they  may  also 
kill. 

The  introduction  of  fluid  medicines  into  the  uterine  cavity  contained  in 
gelatine  capsules  has  been  recommended  by  Sale  and  others,  who  pushed 
the  capsules  beyond  the  internal  os  with  forceps.  Powdered  iodoform 
can  also  be  inserted  into  the  uterus  in  this  way.  I  do  not  believe  that 
this  recommendation  has  been  generally  followed,  although  I  think  the 
plan  a  good  one,  especially  if  the  capsules  can  be  introduced  by  means  of 
a  piston-tube. 

Sponge-teuts  have  also  been  impregnated  with  drugs  in  solution 
(chiefly  carbolic  acid,  zinc,  and  copper  solutions)  which,  of  course,  exerted 
their  local  or  general  effect  when  the  sponge  became  permeated  with  fluid 
from  the  tissues  of  the  uterus.  I  have  frequently  used  carbolic  acid  in 
this  way,  dipping  the  tent  into  the  acid  immediately  before  inserting  it ; 
indeed,  all  sponge -tents  now  made  are  carbolized. 

5.  Ointments. — Any  of  the  drugs  used  for  intra-uterine  medication, 
which  permit  of  being  rubbed  up  with  lard  or  vasehne,  can  be  applied  to 
the  endometrium  through  a  wide-mouthed  sjiinge  or  piston-tube.  Such 
instruments  have  been  devised  by  Barker,  Barnes,  Lente,  and  others,  and 
the  method  is  well  spoken  of  by  these  gentlemen.  It  seems  to  be  espe- 
cially applicable  to  those  cases  in  which  a  gradual  action  and  absorption 
of  the  agent  is  desired.     For  caustic  styptic  and  stimulant  effects  this 


METHODS    OF    MAKIISTG    INTRA-UTERHSTE    APPLICATI0:N"S.        253 

method  is  evidently  not  appropriate,  as  the  dilution  of  the  agent  by  the 
vehicle  softens  its  action.  Thus,  the  iodine  compounds,  mercurial  oint- 
ment, nitrate  of  silver  would  do  good  service  in  hyperplasia  and  endome- 
tritis, if  applied  in  this  form. 

G.  On  a  Caustic-holder. — In  order  to  cauterize  the  endometrium  vrith 
the  solid  nitrate  of  silver,  and  to  avoid  the  excessive  effect  from  a  long 
contact  of  the  agent  with  the  surface  (as  results  when  the  stick  is  deposited 
in  the  cavity  fi'om  a  tube  and  left  to  melt  there),  various  caustic-holders 
have  been  devised,  which,  like  those  of  Scanzoni,  Chiari,  and  Lallemand, 
either  carry  the  stick  of  the  nitrate  into  the  uterine  cavity,  or  (like  that  of 
Barnes  and  Lente)  are  coated  with  the  fused  agent  and  then  inserted.  In 
either  case  the  agent  is  applied  to  the  whole  endometrium  by  moving  the 
point  of  the  caustic-holder  about  in  the  cavity,  until  every  portion  is 
thought  to  be  touched,  and  then  withdrawing  it. 

Where  it  is  indicated  to  use  the  solid  silver-nitrate,  this  method  is  un- 
questionably preferable  to  leaving  the  stick  in  the  uterine  cavity.  I  am 
under  the  impression  that  in  this  country  intra-uterine  applications  are 
but  seldom  made  in  this  manner.  The  caustic-holders  are  introduced 
through  a  speculum  like  a  sound.  The  effects  are  likely  to  be  more  severe 
than  those  of  fluid  applications.  An  ingenious  and  practical  method  of 
applying  the  solid  nitrate  of  silver  to  the  uterine  cavity  for  endometritis 
has  been  devised  by  Dr.  S.  S.  Boyd,  of  Dublin,  Ind.  {American  Practitioner, 
October,  1880).  He  cuts  a  small  silver  female  catheter  in  two,  so  as  to 
have  three  inches  of  the  closed  or  distal  end  in  one  piece.  In  three- 
fourths  of  this  closed  end  he  has  as  many  perforations  made  as  possible 
mthout  materially  weakening  the  instrument,  and  to  the  ojDen  end  of  the 
tube  a  ring  is  soldered  to  which  a  small  cord  is  attached.  After  leaving 
a  slippery-elm  tent  in  the  uterus  overnight  in  order  to  somewhat  dilate  the 
uterine  canal,  he  places  grs.  xv.  of  coarsely  pulverized  nitrate  of  silver  in 
the  tube,  and  confining  it  there  by  pressing  a  little  cotton  on  it,  he  removes 
the  tent  and  inserts  the  charged  tube  through  the  speculum  into  the  uterus 
until  the  tube  touches  the  fundus.  The  cord  is  left  hanging  fi'om  the 
vulva  in  order  that  the  patient  may  remove  it  if  serious  pain  is  felt.  This 
tube  is  left  in  utero  for  three  to  four  hours,  when  the  nitrate  of  silver 
has  been  dissolved,  and  is  then  removed.  By  this  method,  used  once  a 
week  for  four  weeks,  a  patient  who  had  suffered  from  chronic  endometritis 
for  five  years,  and  had  been  treated  by  him  for  two  and  a  half  years  locally 
and  generally  without  success,  was  cured  in  less  than  six  weeks. 

The  comments  attached  to  each  of  the  methods  described  wiU  have 
made  it  apparent  which  form  of  intra-iUeriyie  medication  I  prefer,  as  combin- 
ing the  highest  degree  of  efficiency,  facility,  and  safely.  With  a  moderately  di- 
lated cervical  canal,  I  unquestionably  prefer  the  cotton-wrapped  applicators; 
ivhen  the  canal  is  of  normal  width,  the  medicated  tents  introduced  through  a 
piston-tube  ;  but  ivhen  the  passage  has  been  dilated  by  artificial  means  and  ad- 
mits the  introduction  of  at  least  the  little  finger,  the  most  satisfactory,  safe,  and 
rapid  method  is  to  pass  a  straight  cotton-wrapped  stick  soaked  in  the  fiuid  di- 


254  MINOK    GYNAECOLOGICAL    MAlSriPULATION"S. 

rectly  to  the  fundus.  In  any  case,  tlie  effect  is  immensely  enhanced  by 
leading  a  cone  of  cotton  soaked  in  the  fluid  in  the  uterine  cavity  until  the 
organ  itself  expels  it,  or  the  discharge  from  the  cauterized  endometrium 
loosens  the  cotton  and  permits  its  easy  removaL 

The  choice  of  the  agent  and  the  method  depends,  therefore,  chiefly 
on  the  indication  for  local  treatment  and  the  condition  of  the  uterine 
canal,  but  is  very  often  influenced  by  habit  and  individual  preferences  on 
the  part  of  the  operator.  Thus  some  gynecologists  prefer  iodine  (styptic, 
alterative)  and  impure  carbolic  acid  (stimulant,  irritant)  for  all  the  cases  in 
which  intra-uterine  medication  is  indicated.  Emmet  is  one  of  these,  and  I 
confess  myself,  to  a  certain  degi'ee,  of  the  same  opinion.  Others  praise 
the  solutions  of  the  salts  of  iron,  and  pure  carbolic  or  j)yroligneous  acid, 
for  the  same  purposes,  respectively.  Others,  again,  following  the  lead 
of  Lombe  Atthill,  of  Dublin,  believe  that  fuming  nitric  acid  is  the  one 
agent  for  all  forms  of  intra-uterine  medication.  So  far  as  efficiency  goes, 
I  certainly  agree  with  these  last  named,  and  also  as  regards  the  comj)ara- 
tive  safety  of  the  agent.  But  there  are  very  many  cases  in  which  milder 
means  will  answer  quite  as  well,  and  in  which  it  is  scarcely  proper  to  risk 
converting  the  endometrium  into  a  cicatricial  surface  unless  those  milder 
measures  fail  The  true  and  really  scientific  way  in  the  choice  of  agents 
and  methods  for  intra-uterine  medication  is  to  adapt  the  nature  and  strength 
of  the  remedy  to  the  severity  of  the  disease  ;  to  try  the  effects  of  mild 
measures  before  resorting  to  extreme  means,  and  to  change  the  remedy 
if  a  fair  trial  shows  its  inefficacy.  We  are  prone  to  become  wedded  to 
one  peculiar  j)ractice  or  remedy  which  has  always  served  us  fairly,  and  to 
be  averse  to  trying  others  which  might  do  much  better. 

Precautions. — The  general  rules  to  be  observed  for  all  methods  of  in- 
trauterine  medication  are  :  1.  Clearly  specify  the  indication  and  select 
the  remedy  accordingly.  2.  EHminate  all  counter-indications  and  elements 
of  danger.  3.  Choose  the  method  which  can  be  most  thoroughly,  safely, 
and  rapidly  employed  in  the  given  case.  4.  Dilate  the  cervical  canal 
before  making  the  apiDhcation,  if  such  a  course  appears  necessaiy  to 
thoroughness.  5.  Begin  with  mild  applications  until  the  sensitiveness 
of  the  uterus  is  tested.  6.  Make  the  first  application,  when  possible,  at 
the  house  of  the  patient,  and  keep  her  in  bed  or  in  a  recumbent  posi- 
tion for  at  least  several  houi's  afterward.  7.  Enjoin  upon  all  patients, 
after  every  application,  to  avoid  violent  exercise  or  exposure  to  cold 
during  the  remainder  of  the  da}-.  8.  Use  the  powerful  caustics  (nitric 
and  chromic  acid,  iodized  phenol)  only  after  dilatation  of  the  cervical 
canal  and  at  the  house  of  the  jDatient,  keej)ing  her  in  bed  for  at  least 
twenty-four  hours  after,  and,  if  necessaiy,  giving  her  opiates  to  relieve 
pain  and  possible  inflammatory  reaction.  9.  Kepeat  the  milder  applica- 
tions every  day,  or  other  day,  or  twice  or  once  a  week,  accordingly  as 
the  symptoms  call  for  repetition  ;  the  stronger  agents  only  after  separa- 
tion of  the  slough,  if  still  necessary,  and  if  not  required,  complete  the 
cure  by  the  milder  agents.  10.  Protect  the  cer-vix  and  vagina  by  specula, 
cotton,  and  tampons,   and   by  mopping  up  all  excess.     11.  For    styptic. 


METHODS    OF    MAKING    INTRA-UTERINE    APPLICATIONS.       255 

alterative,  and  absorbent  purposes,  iodine  (j)ure  or  compound)  and  iodized 
phenol  are  tlie  best  agents ;  for  a  styptic  effect  alone,  the  solution  of  the 
persulphate  or  perchloi'ide  of  iron,  mixed  with  glycerine ;  as  a  caustic,  the 
pure  nitric  acid ;  as  stimulants,  pure  and  impure  carbolic  acid,  plain  or  with 
glycerine  ;  as  an  anesthetic  and  alterative,  iodoform.  12.  Occasional  changes 
of  remedies  will,  in  chronic  cases,  hasten  a  cure,  and  entire  cessation  of 
local  treatment  for  a  week  or  more,  every  now  and  then,  is  often  beneficial 
in  giving  nature  an  oj)portunity  to  repair  the  injury.  If  a  wound  or  living 
surface  is  constantly  irritated,  it  very  naturally  is  unable  to  return  to  or 
preserve  its  normal  condition,  and  the  very  means  then  which  are  intended 
to  cure,  serve  to  maintain  the  unhealthy  condition.  13.  Always  tell  the 
patients  that  only  perseverance  will  result  in  recovery,  and  that  a  too 
early  cessation  of  treatment  will  surely  be  followed  by  a  relapse. 

Counter-indications  and  Dangers. 

The  same  conditions  which  prevent  the  use  of  the  sound  or  probe  will, 
to  a  greater  degree,  counter-indicate  applications  to  the  endometrium.  All 
acute  and  subacute  inflammatory  conditions  of  the  uterine  substance  or 
adnexa  are  absolute  counter-indications.  All  such  conditions  in  which  no 
evidence  remains  of  the  inflammation  but  a  tenderness  of  the  thickened 
parametrium  on  pressure,  so-called  "chronic  parametiitis  and  perime- 
tritis," vpill  admit  of  applications,  if  the  gain  is  proportionate  to  the  risk  of 
lighting  up  the  inflammation.  When  the  uterus  is  fixed,  and  the  inflam- 
matory residue  is  so  old  as  to  be  cartilaginous  or  cicatricial,  no  particular 
harm  can  come  from  swabbing  the  endometrium.  But  special  care  should 
be  taken  to  eliminate  eveiy  case  in  which  pressure  in  the  vaginal  vault 
causes  decided  pain,  or  where  the  history  of  the  case  gives  a  tendency  to 
febrile  reaction  after  every  local  interference.  When  I  speak  of  inflam- 
mation as  a  counter-indication,  I  mean,  of  course,  inflammation  of  the 
substance  of  the  uterus,  and  of  the  peritoneum  and  cellular  tissue  sui'- 
rounding  it ;  not  of  the  mucous  membrane,  which  is  jDrecisely  one  of  the 
conditions  we  desire  to  cure  by  applications. 

Uterine  hemorrhage  does  not  constitute  an  objection,  when  it  is  this  very 
symptom  which  we  are  consulted  for.  I  constantly  ajDply  tincture  of  iodine 
or  tincture  of  the  persulphate  of  iron  to  the  endometrium  during  hemor- 
rhage, either  profuse  menstrual,  or  intermenstrual,  when  general  remedies 
fail.  The  objection  to  an  examination  so  frequently  made  by  these 
patients,  that  they  are  flowing,  is  precisely  the  reason  why  they  should  be 
examined  and  its  cause  ascertained,  and  if  this  fails,  the  flow  should  be  ar- 
rested by  local  means,  either  repeated  vaginal  tamponing,  or  iuti-a-uterine 
applications,  or  both. 

The  danger  of  these  applications  appears  from  the  foregoing  remarks, 
viz.,  the  lighting  up  of  a  fresh  or  the  rekindling  of  an  old,  pelvic  peritoni- 
tis or  cellahtis.  There  can  be  no  question  that  this  danger  is  inin  with 
every  application  beyond  the  intei'nal  os.  But  out  of  thousands  of  appli- 
cations of  the  kind,  the  agents  chiefly  used  being  tincture  of  iodine  and 


256  MIISrOE    GYNECOLOGICAL    MAISTIPULATIONS. 

carbolic  acid,  witli  a  fair  number  of  strong  nitric  acid,  I  have  but  one  in- 
stance in  "which,  an  inflammatory  reaction  followed  ;  and  even  in  that  case 
the  dull  curette  which  was  first  emjployed  may  faii-ly  bear  its  share  of  the 
blame. 

The  usual  sensation  felt  after  any  intra-uterine  application  is  that  of  a 
warmth,  a  glow,  in  the  suprapubic  region.  This  lasts  from  several  minutes 
to  several  hours.  Not  unfrequently  my  patients  have  complained  of  su- 
prapubic soreness  for  a  day,  or  there  has  been  actual  pain  for  the  same 
time.  Uterine  colic  (sharp  contractile  pain)  was  rare,  and  usually  in 
cases  where  the  internal  os  was  narrow,  and  coagula  or  albuminates  were 
retained  in  utero.  In  four  cases  only  did  I  observe  decided  shock  :  1. 
After  application  of  strong  nitric  acid  through  the  appKcator-syringe  in 
an  undilated  uterus,  at  the  home  of  the  patient,  who  collapsed  decidedly, 
and  required  repeated  stimulation  with  brandy  and  ammonia,  and  hot  bot- 
tles all  about  her,  before  reaction  set  in  ;  no  further  bad  results  followed. 
2.  After  the  introduction  of  a  solution  of  nitrate  of  silver,  3  j.  to  §  j.  by  the 
applicator-syringe  in  chronic  endometritis.  Normal  cervical  canal ;  hj'ster- 
ical  patient ;  severe  uterine  colic  ;  collapse  ;  vomiting ;  brandy  and  hypoder- 
mic of  morphine  ;  able  to  leave  office  in  carriage  after  two  hours ;  confined 
to  bed  for  several  days  by  abdominal  pain,  but  nothing  further.  3.  After 
application  of  Squibb's  impure  carbohe  acid,  by  applicator-syringe  in  my 
office.  Uterine  canal,  normal ;  coUajJse,  syncope,  lasting  half  an  hour,  no 
stimulus  needed,  no  bad  results.  4.  Virgin,  Chiu'chill's  tincture  of  iodine 
for  menorrhagia  ;  repeated  previous  applications  on  cotton-wrapped  apph- 
cator  entirely  painless  and  innocuous  ;  after  single  careful  use  of  applicator- 
s^Tinge  immediate  \iolent  pain  in  right  ovarian  region,  moderate  collaj)se ; 
morphine  hypodermically  ;  no  subsequent  bad  result.  These  four  cases 
all  occurred  after  the  use  of  the  applicatoi'-syringe,  and  the  shock  may, 
therefore,  possibly  have  been  due  to  the  rajDid  saturation  of  the  cotton,  and 
escape  of  a  few  drop»s  into  the  uterine  cavity.  I  certainly  have  seen  no  such 
symptoms  follow  the  use  of  the  ordinary  cotton-wrajoped  applicator. 

At  a  discussion  on  Intra-uterine  Medication,  held  at  the  fourth  annual 
meeting  of  the  American  Gynecological  Society,  in  Baltimore,  in  Se2otem- 
ber,  1879,  so  careful  and  experienced  an  oj)erator  as  Dr.  WiUiam  Goodell,, 
of  Philadelphia,  expressed  his  growing  satisfaction  in  the  use  of  intra- 
uterine injections,  which  he  makes  with  Buttles'  sjTinge,  throwing  in 
carefully  four  to  eight  drops  of  joure  carbolic  acid,  or  iodized  phenol,  with 
a  small  amount  of  hydrate  of  chloral  added.  He  obtains  much  better  re- 
sults from  these  injections  than  from  applications,  and  taking  care  to  have 
the  canal  always  patulous,  fears  no  bad  consequences  therefrom.  Dr. 
Goodell's  experience  certainly  should  carry  gi-eat  weight  with  it.  But  in 
the  discussion  referred  to  he  was  almost  alone  in  his  recommendation  of 
iutra-uterine  injections,  the  large  majority  of  the  gentlemen  present,  all 
men  of  large  experience,  expressing  themselves  decidedly  against  them. 
In  France  Leblond  has  recently  reported  a  small  series  of  cases  in  which 
the}'  were  used  without  danger  and  with  success.  But  he,  like  Goodell 
and  all  who  use  or  permit  them,  makes  a  widely  patulous  uterine  canal  a 


METHODS    OF    MAKING    INTRA-UTEKINE    APPLICATIONS.        257 

sme  qua  non  ;  and  that  being  present,  as  already  stated,  I  should  prefer  to 
do  away  with  all  risk  and  swab  out  the  cavity  with  the  straight  cotton- 
wrapped  stick,  either  unguarded  or  through  a  straight  metal  or  glass 
canula. 

As  regards  the  danger  of  producing  inflammation  by  the  aj^iDlication 
to  the  iiterine  cavity  of  strong  nitric  acid,  I  am  disposed  to  agree  with 
Atthill,  who  believes  it  to  be  as  safe  as  it  is  efficient.  Only  once  have  I 
seen  a  reaction  follow  the  thorough  repeated  swabbing  of  the  endome- 
trium with  nitric  acid,  even  after  the  superficial  portion  of  the  In-perplastic 
mucous  membrane  had  been  removed  with  the  dull  curette,  when  the 
uterine  canal  has  been  so  freely  dilated  as  to  readily  admit  the  cotton- 
wrapped  stick  and  allow  the  escape  of  the  secretions.  The  immediate,  pain 
of  the  ajDplication  even  hardly  exceeds  that  of  iodine  or  carbolic  acid.  In 
the  one  exception  referred  to,  a  pelvic  cellulitis  followed  the  curetting  and 
application  to  the  endometrium  of  nitric  acid. 

Besides  the  immediate  danger  of  inflammation,  there  is  a  secondary 
accident  to  be  feared  from  the  most  powerful  apj)lications,  the  escharotics, 
only,  and  that  is  the  cicatricial  contraction  of  the  internal  os,  the  seahno-up 
of  the  uterine  cavity.  Barker  and  H.  P.  C.  Wilson  rejDort  cases  of  this  ac- 
cident after  nitric  acid  ;  the  constriction  of  the  external  os  followino-  the 
sohd  nitrate  of  silver  has  been  already  referred  to.  I  have  seen  no  such 
result  after  nitric  acid  in  any  of  my  cases,  but  can  readily  understand  how 
it  might  occur.  Avoidance  of  too  deep  and  too  frequent  cauterization, 
and  frequent  sounding  of  the  uterine  canal  for  some  time  after,  wiU  usually 
prevent  such  stenosis. 

Therajyeutic  Value. — After  this  long  and  elaborate  discussion  of  intra- 
uterine medication,  it  may  seem  strange  that  I  should  think  it  necessary 
to  say  anything  as  to  the  theraj)eutic  value  of  this  treatment.  But,  in 
spite  of  the  universal  employment  of  the  various  methods  described,  and 
the  ease  with  which  the  results  of  the  treatment  can  be  controlled  and  esti- 
mated, weighty  authority  still  seems  to  doubt  their  rerouted  efficacy.  At 
the  meeting  of  the  American  Gynecological  Society  above  refeiTed  to,  the 
President,  Dr.  T.  G.  Thomas,  expressed  himself  as  follows  :  "  While  intra- 
uterine medication  beyond  the  internal  os  is  in  many  cases  exceedingly 
beneficial,  I  feel  fully  inajn-essed  with  the  idea  that,  as  a  general  rule  of 
practice,  it  is  much  more  honored  in  its  breach  than  in  its  observance." 
He  then  goes  on  to  exjjlain  this  opinion  by  saying,  that  uterine  catai-rh 
usually  depends  on  conditions  not  inherent  to  the  mucous  membrane  of 
the  cavity  itself,  but  consisting  in  displacement,  subinvolution  or  hvper- 
l^lasia  of  the  uterus,  laceration  of  the  cervix  ;  or  the  catarrh  may  be  due  to 
fungoid  development  of  the  mucous  membrane.  The  proper  method  to 
cure  the  catarrh  in  these  cases  is  to  remove  its  primary  cause,  rectify  the 
displacement,  reduce  the  hyperplasia,  stimulate  the  uterus  to  involution, 
sew  up  the  cervix,  curette  off  the  fungoid  growths  of  the  mucous  membrane. 
He  then  admits  the  pi-esence  of  idioj^athic  endometritis,  but  omits  to  tell 
us  how  he  cures  it,  although  admitting  the  j^i'opriety  of  intra-uterine  medi- 
cation in  these  cases.  What  Dr.  Thomas  says  as  regai-ds  first  remo^-inR- 
17  ^  O  O 


258  MI]SrOE    GYNECOLOGICAL    MANIPULATIONS. 

the  cause  of  the  endometritis  is  very  true,  and  the  only  rational  mode  of 
procedure  ;  but,  how  arc  we  to  relieve  the  hypei'plasia,  or  cure  hemorrhage 
in  which  the  curette  fails  to  show  the  presence  of  fungoid  or  granular  de- 
generation of  the  mucosa  ;  or  stimulate  a  torpid  uterus  to  involution  or 
menstruation,  without,  at  the  least,  the  assistance  of  intra-uterine  medica- 
tion? While  I  do  not  go  so  far  as  Dr.  Goodell,  who  passes  every  applica- 
tion to  the  fundus,  even  though  there  is  no  evidence  that  the  catarrh  ex- 
tends beyond  the  internal  os,  and  while  I  believe  that  the  disease  is  in 
many  cases  confined  to  the  cervical  cavity,  and  the  medication,  therefore, 
need  not  be  carried  higher  up,  I  am  compelled  to  confess  that  I  fail  to  see 
how  the  numerous  cases  of  chronic  endometritis,  hyperplasia,  subinvolu- 
tion, hemorrhage  depending  on  pulpiness  or  flabbiness  of  the  endome- 
trium, can  be  cured  without  local  ajDplications  to  the  uterine  cavity.  Of 
the  value  of  local  cauterization  of  malignant  growths  in  the  uterine  cavity 
there  can  be  no  question,  although  of  course  such  treatment  is  but 
palhative. 

VII.    DILATATION   OF   THE   UTERUS. 

In  the  chapter  on  Examination  I  have  ah-eady  spoken  of  dilatation  of 
the  uterus  for  diagnostic  purposes.  How  to  accomplish  this  dilatation 
not  only  for  diagnosis,  but  also,  and  chiefly,  as  a  means  of  treatment,  is 
the  subject  of  this  section. 

An  indispensable  condition  to  all  measures  for  dilatation  of  the  uterine 
canal  is  the  patency  of  the  vagina  and  accessibility  of  the  cei-vix.  In  the 
absence  of  this  condition,  the  dilatation  of  the  vaginal  canal  by  tampons, 
sj)ecula,  bougies,  expanding  instruments,  and  the  employment  of  means 
calculated  to  increase  the  mobihty  of  the  uterus  (iodine  to  vaginal  vault, 
traction  on  cervix),  should  necessarily  precede  the  attempts  at  expansion 
of  the  uterine  canal. 

The  operation  of  opening  up  the  uterine  cavity  to  the  finger  and  in- 
struments may  properly  be  divided  into  two  main  sections,  according  as 
the  dilatation  is  performed  with  or  without  cutting  instruments.  I  shall 
first  describe  the  various  methods  without  cutting  instruments,  and  then 
speak  of  the  operation  for  opening  the  uterine  cavity  with  knife  or  scis- 
sors, the  so-called  "  bloody"  dilatation  of  the  canal,  in  contradistinction  to 
the  other  "  bloodless  "  procedure.  The  cutting  operation  is  naturally  a 
rapid  and  immediate  method. 

Dilatation  without  Cutting  Instbuments  (Bloody  Dilatation). 

Methods  and  Instruments,  ojid  How  to  Use  Them.  —  There  are  two 
methods  of  dilating  the  uterine  canal  without  knife  or  scissors,  and  they 
differ  simply  in  the  degree  of  rapidity  with  which  the  dilatation  is  accom- 
plished. 

a.  Rapid  dilatation  (that  is,  within  fifteen  minutes,  and  at  one  sitting) 
is  effected  by  means  of  graduated  sound-like  instruments,  which  are  forced 


DILATATION"    WITHOUT    CUTTING    INSTRUMENTS. 


259 


througli  the  uterine  canal  one  after  the  other  ;  or  by  steel  two-  or  three- 
branched  instruments,  which  are  introduced  closed  and  then  expanded  by 
an  external  mechanism  ;  or  by  tubes  or  bags  of  rubber  which  are  inserted 
in  a  collapsed  condition,  and  are  then  inflated  with  air  or  water  ;  or  by  the 
finger. 

Graduated  Sounds. — In  1870  the  late  Dr.  E.  R  Peaslee  devised  a  series 
of  graduated  metal  sounds  which  were  arranged  to  screw  into  one  handle. 
There  were  either  five  or  three  in  the  set.     Later  these  dilators  were  made 


Fig.  115. — Peaslee's  Uterine  Dilators. 

of  hard  rubber.  Dr.  Horace  T.  Hanks  modified  them  slightly  by  placing 
two  dilators  of  difterent  size  on  one  handle,  and  making  eight  sizes  instead 
of  five.  Both  these  instruments  are  but  modifications  of  the  old  dilators 
of  Simpson,  of  which  there  were  twelve  in  a  set.  They  were  destined  to 
be  left  in  situ  for  an  hour  or  more,  and  the  handle  is  therefore  provided 
"with  a  slide  by  which  the  dilator  can  be  detached  when  it  has  been  intro- 
duced. A  tampon  keeps  it  in  place,  and  it  is  withdrawn  by  the  string  at- 
tached to  it.  All  these  dilators  are  provided  with  a  circular  enlargement 
at  a  distance  of  about  two  inches  from  the  point  to  prevent  their  too  deep 
insertion.  These  sound-dilators  are  introduced  in  the  following  manner  : 
Through  the  speculum  (large  tubular,  valvular,  or  Sims)  the  cer\dx  is 
seized  with  a  stout  tenaculum  (best  a  double  tenaculum)  which  seizes  one 
lip  of  the  cervix  between  its  blades,  and  the  uterus  is  slightly  di-awn  down 
and  straightened.  The  direction  of  the  uterine  canal  having  been  ascer- 
tained by  the  sound  or  probe,  the  smalles<>sized  dilator  is  inserted  into  the 


Fig.  116.— Hank.s'  Uterine  Dilator. 

OS  and  forced  upward  toward  the  internal  os,  the  cervix  being  steadily  held 
by  the  tenaculum.  As  soon  as  the  whole  dilator  has  been  introduced,  it  is 
allowed  to  remain  a  few  moments,  then  withdrawn  and  the  next  size  forced 
in,  and  so  on  until  the  desired  amount  or  the  limit  of  dilatation  has  been 
reached.  The  last  dilator  may  be  allowed  to  remain  in  utero  for  fifteen 
minutes  or  longer,  or,  if  only  temporary  dilatation  is  desired,  may  be  re- 
moved at  once  when  the  desired  degree  has  been  accompUshed.  It  is  of 
prime  importance  in  using  these  dilators  that  there  be  as  httle  difference 


260  MIlSrOE    GYNECOLOGICAL    MAKIPULATIOlSrS. 

as  possible  between  the  sizes.  The  objection  to  those  of  Peaslee  and 
Hanks  is  that  there  are  not  enough  of  them.  To  overcome  this  difficulty 
Professor  Hegar,  of  Germany,  has  constructed  a  series  of  about  twenty-five 
dilators,  ranging'  from  the  size  of  a  fine  probe  to  an  inch  in  diameter.  By 
means  of  these  the  most  rigid  cervical  canal  can  be  easily  dilated  within 
thirty  minutes. 

This  maneuvre  may  be  practised  in  the  office  or  outdoor  clinic,  if  it 
is  not  attended  with  too  much  pain  or  the  degree  of  dilatation  desired 
is  not  very  great.  The  ease  with  which  the  dilatation  succeeds  depends 
entirely  upon  the  amount  of  elasticity  and  density  of  the  uterine  tissue. 
Some  uteri  are  dilated  with  scarcely  any  force,  others  resist  even  the 
most  persistent  efforts.  Upon  this  degree  of  resistance  will  depend,  to 
a  great  extent,  the  amount  of  pain  experienced  by  the  patient,  and 
the  consequent  advisability  of  performing  the  operation  at  the  home  of 
the  patient,  putting  her  under  an  anesthetic,  and  keeping  her  in  bed  for 
a  day  or  two  after.  If  a  permanent  and  very  thorough  dilatation  is  in- 
tended, the  latter  precautions  are  certainly  advisable.  I  have  frequently 
practised  dilatation  on  outdoor  patients,  but  have  never  been  able  to 
obtain  more  than  a  moderate  and  temporary  result  unless  the  patient 
was  anesthetized,  and  the  operation  was  thoroughly  done. 

If  a  sufficient  dilatation  and  the  desired  object  are  obtained  at  one 
sitting,  of  course  it  need  not  be  repeated  ;  but  if  a  systematic  gradual 
dilatation  of  the  uterine  canal  is  intended  (as  in  stenosis),  sterility,  dys- 
menorrhea, flexion),  the  sitting  should  be  repeated  every  day  or  two,  ac- 
cording to  necessity  and  the  endurance  of  the  patient, 

A  very  thorough  expansion  of  the  uterine  canal  can  certainly  be  ac- 
complished by  these  graduated  sounds,  provided  the  tissue  of  the  uterus 
is  not  too  dense  and  a  sufiiciently  firm  hold  can  be  secured  of  the  cer- 
vix to  resist  the  forcible  upward  motion  of  the  sound.  And  these  two 
points  are  precisely  the  great  objections  to  these  instruments.  The  force 
required  to  thrust  the  sounds  through  the  narrowest  portion  of  the 
uterine  canal,  the  internal  os,  and  the  part  immediately  above  it  (the 
isthmus  uteri  of  Spiegelberg)  is  usually  very  great,  so  gTeat,  indeed,  that 
the  cervix  is  very  liable  to  be  badly  torn  by  the  tenaculum.  And  only 
when  the  tissue  is  but  moderately  dense  and  fairly  elastic  is  it  possible 
to  pass  any  but  the  smallest-sized  dilators.  This  is  especially  the  case  in 
the  long  conical  cervices  of  nulliparous  women,  in  whom  this  method 
of  treatment  is  specially  indicated.  It  is  evident  that  a  certain  degree 
of  force  is  i-equired  to  pass  even  a  wedge  through  a  movable  body,  and 
the  amount  of  traction  necessary  to  counteract  this  force  and  steady  this 
movable  body,  must,  of  course,  be  proportionate.  The  constriction  once 
overcome,  however,  and  the  uterus  thoroughly  dilated,  the  result  is  usually 
a  more  permanent  one,  because  the  expansion  is  uniform  in  every  direc- 
tion, than  when  the  branched  dilators  are  used. 

The  degree  of  dilatation  differs  with  the  indication.  If  it  is  desired  to 
introduce  the  finger,  of  course  that  size  must  be  obtained,  and  several 
daily  sittings  are  often  required.     If  it  is  merely  intended  to  open  the 


DILATATIOI^    WITHOUT    CUTTIN^G    IHSTEUMENTS.  261 

canal  sufficiently  to  allow  tlie  more  ready  escape  of  ttie  menstnial  fluid,  or 
the  entrance  of  tlie  spermatozoa,  a  dilatation  up  to  one-fourth  of  an  inch 
is  all  that  is  necessary.  In  the  latter  eases  the  treatment,  in  order  to 
achieve  permanent  results,  generally  requires  to  be  continued  for  some 
months,  the  sittings  being  gradually  diminished  until  the  permanent  pat-, 
ency  of  the  canal  renders  them  no  longer  necessary. 

The  uterine  canal,  as  a  rule,  contracts  very  rapidly  after  dilatation, 
and  such  cases  in  Avhich  it  is  desired  to  maintain  the  canal  at  a  certain 
dimension  need  frequent  revision,  and,  as  the  occasion  may  be,  corre- 
sponding repetition  of  the  treatment.  Thus,  in  dysmenorrhea  or  sterility 
with  hard,  long,  slender  cervix,  and  narrow,  perhaps  flexed,  canal,  the  dila- 
tation may  require  to  be  repeated  every  day  for  some  weeks,  and  once  or 
twice  a  week  for  several  months  before  the  canal  remains  permanently 
open. 

In  order  to  avoid  the  laceration  of  the  cervix,  which  almost  invariably 
ensues  from  the  tenaculum  when  any  considerable  force  is  required  to 
pass  the  sound  dilators  through  the  cervical  canal.  Professor  Fritsch,  of 
Breslau,  has  recommended  a  method  of  introducing  these  dilators,  which 
is  certainly  original,  and,  I  should  think,  effective.  He  uses  steel  sounds, 
the  thinnest  of  which  has  a  diameter  of  0.5  mm.,  the  largest  15  mm.,  with 
three  intermediate  sizes,  7|,  94-,  12f  mm.  He  puts  the  patient  under 
chloroform,  and  having  explored  the  way  with  the  sound  in  the  ordinary 
manner  (the  patient  on  her  back,  without  speculum)  he  inserts  the  point 
of  the  sound  into  the  cervical  canal,  and  supporting  it  with  the  intra- 
vaginal  finger,  presses  it  firmly  upAvard  in  the  dii-ection  of  the  internal  os, 
at  the  same  time  the  outer  hand  grasps  the  fundus  uteri  and  steadily 
pushes  it  down  over  the  sound,  as  a  glove  is  slipped  over  the  finger.  This 
sound  is  then  replaced  by  a  larger  one,  and  so  on.  Fxitsch  admits  that 
the  force'  needed  to  accomplish  this  is  very  great,  and  would  be  entirely 
unjustifiable  if  the  uterus  were  not  well  watched  by  the  outer  hand.  But 
he  is,  no'  doubt,  right  in  asserting  that  such  a  force  is  allowable  when  ap- 
plied in  this  manner,  and  succeeds  in  its  object,  while  a  lesser  force  applied 
without  the  assisting  outer  hand  would  fail  or  be  injurious.  The  great 
point  about  this  plan  is  that  the  dilator  is  not  forced  into  the  uterus,  but 
the  latter  pushed  over  the  dilator.  Fritsch  goes  so  far  as  to  discard  aU 
methods  of  slow  dilatation  when  the  object  is  merely  to  dilate  the  uterus. 
He  has  witnessed  no  bad  results  from  the  force  employed.  The  jDlan  seems 
to  me  an  excellent  one,  far  superior  to  the  old  method  of  forcing  the  dila- 
tors up  through  the  speculum,  while  the  tenaculum  holds  the  cervix.  It 
Avould  probably  be  feasible  only  in  those  cases  in  which  the  fundus  can 
be  plainly  mapped  out  by  palpation,  and  grasped  by  the  outer  hand  ;  in 
stout  people,  or  with  very  rigid  abdominal  walls,  this  would  not  be  possi- 
ble. But  in  cases  where  an  angle  of  flexion  forms  an  obstacle  to  the  di- 
lator, the  manipulation  of  the  uterus  by  the  outer  hand  would  straighten 
the  canal  and  facihtate  the  passage  of  the  internal  os.  I  have  repeatedly 
succeeded  in  introducing  a  stem-pessary  in  this  manner  when  it  was  im- 
possible to  get  it  through  the  flexed  canal  in  the  usual  manner  (on  a  sty- 


262 


MI]SrOR    GYISTECOLOGICAL    MANIPULATIONS. 


let  through  a  Sims  speculum).  It  would  probably  be  necessary  to  have 
the  sounds  all  made  of  steel  and  in  one  piece  for  this  method,  in  order  to 
insure  sufficient  stififness  and  inflexibility. 

For  the  rapid  dilatation  of  an  already  partly  dilated  cervical  canal,  as 
at  the  beginning  of  a  miscarriage,  or  in  rigidity  of  the  external  os  during 
labor  at  term,  or  for  the  removal  of  intra-uterine  polypi  and  fibroids.  Dr. 
Hanks  has  had  constructed  a  series  of  much  larger,  olive-shaped  dilators 
of  hard  rubber,  \?^hich  are  attached  to  a  handle  by  a  screw,  and  are  iutro- 


FiG.  117. — Hanks'  Large  Cervical  Dilators. 


duced  through  a  speculum  precisely  like  the  smaller  sizes.  They  are  de- 
signed to  take  the  place  of  Barnes'  obstetric  dilators,  which  often  burst 
and  are  liable  to  spoil.  The  advantage  of  having  an  instrument  by  which 
the  cervix  can  be  immediately  dilated  when  it  is  desired  to  remove  a  re- 
tained placenta  after  a  miscarriage,  can  be  apjDreciated  only  by  those  who 
have  labored  hard  for  an  hour  or  more  to  effect  this  through  a  canal  barely 
passable  for  one  finger. 

Steel-branched  Dilators. — The  principle  of  construction  and  mechanism 
of  all  the  instruments  of  this  class  is  the  same,  viz.,  two,  tliree,  or  four 
sound-shaped  blades,  which  unite  in  one  shaft,  are  introduced  through 
the  internal  os  in  the  closed  condition,  and  are  then  separated  by  a  con- 
trivance in  the  handle  to  any  desired  width  within  the  limits  of  expansion 
peculiar  to  each  instrument.  Instruments  of  this  kind  have  been  devised 
by  Simpson,  Priestley,  Sims  (three  blades),  Nott,  Hunter,  EUwood  Wilson, 


Fig.  118.— Sims'  Uterine  Dilator. 


White,  Ellinger,  Palmer,  Ball,  and  various  others.  Those  of  Sims,  Wilson, 
Elhnger,  and  Palmer  are  probably  best  known  and  most  used  by  the  pro- 
fession. 

That  of  Ball  is,  perhaps,  the  most  powerful  instrument  of  the  collection. 
The  mechanism  of  these  instruments  is  plainly  shown  in  the  cuts. 

The  intra-uterine  blades  are  two  and  one-half  inches  long,  slender, 
rounded,  and,  when  separated,  parallel  to  each  other,  in  order  to  secure  an 
equal  expansion  of  the  internal  os  with  the  rest  of  the  canal.     But,  as  a 


DILATATION"    WITHOUT    CUTTING    INSTRUMEI^TS. 


263 


rule,  they  feather  slightly,  and  this  is  as  it  should  be,  to  prevent  a  too 
powerful  expansion  at  the  most  dangerous  point  of  the  uterine  canal.  That 
of  Ball  does  not  feather,  and  any  of  the  others  can  be  made  perfectly  rigid 
by  simply  increasing  the  size  of  the  blades.  The  rounded  point  of  the 
united  blades  should  but  shghtly  exceed  in  size  that  of  the  ordinary  sound, 
so  that  it  can  be  passed 
through  any  normal  in- 
ternal OS.  At  the  junc- 
tion  of  blades  and 
shank,  there  is  an  angle 
of  expansion  to  show 
that  the  limit  of  the  nor- 
mal uterine  cavity  has 
been  reached  when  this 
point  is  at  the  external 

OS. 

I  formerly  used  El- 
linger's  dilator,  which  I 
brought  with  me  from 
Stuttgart,  the  home  of 
its  inventor,  but  I  now 
prefer  that  of  Palmer, 
which  is  rather  more 
powerful,  does  not 
feather,  and  the  action 
of  which  is  regulated 
and  maintained  by  a 
screw  in  the  handle. 

The  limit  of  expan- 
sion of  the  blades  is  one 
inch  to  one  and  one-half 
inch,  but  this  is  seldom 
required.  In  ordinary 
daily  practice  one-half 
inch  is  the  limit  to  which 
dilatation  should  or 
need  be  earned. 

These  dilators  can  be 
either  introduced  on  the 
finger  alone,  like  the 
sound,  or  through  any  speculum  which  is  roomy  enough  to  allow  the  ma- 
nipulation of  the  handle  generally  necessary  to  guide  the  point  through 
the  internal  os.  In  either  case  the  direction  and  mdtli  of  the  canal  should 
have  been  ascertained  by  the  sound  before  attempting  to  introduce  the  di- 
lator. If  a  speculum  is  used  the  cervix  may  be  steadied  by  the  tenaculum 
in  the  anterior  lip,  or  it  may  be  dispensed  with  if  the  uterus  is  not  very 
movable.     The  dilator  having  been  warmed  and  well  greased,  is  inserted 


Fig.  120. — Palmer's  Uterine 
Dilator. 


Fig.  119.— ElIinger'B  Uterine 
Dilator. 


2Q4: 


MINOK    GYNECOLOGICAL    MAmPULATIONS. 


into  the  cervical  canal,  the  right  hand  holding  it  between  thumb  and  first 
two  fingers  like  a  pen,  and  when  it  has  been  introduced  as  fai-  as  the  ex- 
pansion or  angle  where  the  intra-uterine  portion  begins,  the  blades  are 
gently  separated  either  by  approximating  the  handles,  or  turning  the  screw 
in  the  handle,  in  accordance  with  the  construction  of  the 
instrument.  In  EUinger's  instmment  the  compression 
of  the  handles  and  expansion  of  the  blades  is  regulated 
merely  by  the  pressure  of  the  hand,  and  is  therefore 
liable  to  be  more  sudden,  forcible,  and  unequal.  The 
addition  of  a  screw  to  the  crossbar  would  be  useful,  and 
would  enable  the  operator  to  maintain  a  certain  amount 
of  dilatation  without  active  movement  on  his  part.  All 
the  other  dilators  act  by  means  of  a  screw  in  the  handle. 
If  a  Sims  speculum  is  used,  the  point  of  the  dilator  may 
be  gently  pressed  through  the  internal  os  by  resting  the 
backs  of  the  angle  of  the  instrument  (where  the  blades 
begin)  against  the  blade  of  the  speculum  in  the  vagina, 
and  using  this  j)oint  as  a  fulcrum.  The  j)oint  of  the 
dilator  wiU  then  usually  shp  through  the  internal  os  with- 
out further  trouble.  Care  should  be  taken  to  use  but 
very  little  force,  else  the  point  might  suddenly  strike 
agamst  the  fundus.  If  the  internal  os  should  prove  too 
narrow,  a  smaller  dilator  must  be  used,  or  the  smallest 
size  of  Hanks'  sounds  may  first  be  inserted.  But  the  ar- 
rest of  the  point  by  a  jDOcket  or  rugosity  in  the  cervical 
mucous  membrane  should  not  be  mistaken  for  a  naiTow 
internal  os.     The  sound  will  show  the  way. 

The  amount  of  dilatation  to  be  employed  or  allowed 
in  any  given  case  will  depend  upon  the  object  desired, 
the  sensibihty  of  the  patient,  and  the  dilatability  of  the 
uterus.  As  a  rule,  in  ordinary  dilatation  for  the  jDui-pose 
of  facilitating  intra-uterine  applications,  and  in  dysmen- 
orrhea and  sterility,  an  expansion  of  the  blades  to  the 
width  of  one-fourth  to  one-half  inch  is  all  that  is  re- 
quh'ed.  Indeed,  in  many  cases,  it  is  aU  that  is  feasible 
at  one  attempt,  unless  the  patient  be  anesthetized.  With 
EUinger's  and  Wilson's  dilators  the  amount  of  internal 
expansion  can  be  read  on  the  graduated  crossbar  at  the 
handles  ;  in  the  other  instruments  it  must  be  gniessed  by  the  number  of 
turns  of  the  screw,  as  previously  ascertained.  When  the  dilatation  has 
been  maintained  for  a  few  minutes,  the  number  of  which  dej)ends  upon 
the  permanency  of  the  result  desired  (three  to  fifteen  under  ordinary  cu'- 
cumstances),  the  instrument  is  closed  and  withdrawn.  If  there  is  any  hem- 
orrhage, the  vagina  is  cleared  of  the  clots  with  cotton  on  a  dressing-forcej)S, 
and  a  few  flat  tampons  may  be  introduced,  if  thought  ad-sdsable.  The  pa- 
tient should  be  directed  to  remain  quiet  for  the  remainder  of  the  day,  and 
particularly  to  avoid  exposure  to  cold. 


Fig.  lai.— Bairs 
Uterine  Dilator. 


DILATATION    WITHOUT    CUTTI]S-G    II^^STRUMENTS.  265 

The  pain  experienced  during  this  operation  corresj)onds  to  the  amount 
of  dilatation  and  the  sensitiveness  of  the  patient.  It  is  generally  quite 
acute  so  long  as  the  blades  are  still  being  expanded,  but  soon  subsides 
when  they  are  kept  immovable,  and  rarely  continues  after  the  instrument 
is  withdrawn.  It  certainly  is  very  much  less  than  that  endured  during 
dilatation  with  the  graduated  sounds  ;  at  least  that  is  my  experience.  Oc- 
casionally the  pain  lasts  during  the  remainder  of  the  day. 

As  a  rule,  it  is  not  necessary  to  anesthetize  the  jDatient  when  no  greater 
expansion  than  one-fourth  inch  is  desu-ed.  Therefore,  the  operation  may 
be  performed  in  the  consulting-room  or  outdoor  clinic,  and  I  have  so  done 
it  hundreds  of  times,  lveej)ing  the  patients  for  half  an  hour  afterward,  and 
then  sending  them  to  their  homes,  often  miles  away.  In  but  two  instances 
was  a  bad  result  reported  to  me  after  this  treatment.  In  one  case  quite  a 
profuse  hemorrhage  followed  the  dilatation,  and  there  was  considerable 
peri-uterine  tenderness  for  a  few  days  ;  in  the  other,  a  sharp  attack  of 
pelvic  peritonitis  occurred,  but  as  curetting  and  iodine  apphcation  to  the 
endometrium  were  practised  at  the  same  sitting,  the  blame  may  fairly  be 
divided  between  these  three  manipulations. 

When  more  thorough  dilatation  is  intended,  the  operation  should  al- 
ways be  done  under  anesthesia  at  the  home  of  the  patient,  who  should' be 
kept  in  bed  for  several  days  and  treated  prophylactically  (morphine,  ice  on 
abdomen)  against  possible  peritonitis  or  cellulitis.  If  very  sensitive,  opium 
suppositories  may  be  given  for  a  day  before  the  operation. 

The  frequency  of  this  dilatation  is  subject  to  the  same  niles  which 
guide  dilatation  by  sounds,  viz.,  the  indication,  and  the  endurance  of  the 
patient.  I  have  I'epeated  it  three  times  a  week  for  several  months  in  dys- 
menorrhea and  sterility,  with  decided  benefit  as  regards  the  former  diffi- 
culty and  occasional  relief  of  the  latter. 

In  sharp  flexion  or  contracted  uterine  canal,  particularly  with  pointed 
conical  ceiTix,  where  it  is  specially  desii'able  to  keep  the  canal  dilated  and 
the  external  os  open  and  thus  facilitate  conception,  I  have  seen  very  good 
results  from  performing  thorough  dilatation  under  an  anesthetic  at  the 
home  of  the  patient  with  one  of  these  divergent  dilators,  or  by  repeated 
introduction  of  tupelo-tents  (hereafter  to  be  described),  and  then  inserting 
a  soHd  glass  or  hard-rubber  stem  and  allowing  it  to  be  worn  for  a  number 
of  months.  When  the  canal  seems  permanently  dilated  the  plug  may  be 
removed,  and  an  opportrmity  be  given  for  conception  to  take  place.  A 
long  retention  of  these  stems  is  hable  to  produce  a  chi-onic  cenical  catarrh, 
and  of  course  the  usual  precautions  against  inflammatory  reaction  attend- 
ing these  stems  (see  chapter  on  Intra-uterine  Stems)  should  be  observed. 
Frequent  examinations  are  required  to  guard  against  reclosiu'e  of  the  uter- 
ine canal,  care  being  taken  to  examine  and,  if  necessary,  dilate  only  imme- 
diately after  a  menstrual  period  so  as  not  to  produce  an  abortion. 

It  may  be  stated  that  in  an  emergency  (such  as  an  application  for  hem- 
oiThage,  introduction  of  curette)  the  ordinary  uteiine  dressing-forceps 
may  be  inserted  and  used  as  a  dilator-,  if  the  canal  is  not  abnormally  con- 
stricted. 


266  MINOR    GYNECOLOGICAL    MANIPULATIONS. 

One  of  the  great  objections  to  these  complicated  dilators  is  the  diffi- 
culty in  keeping  them  clean.  They  should  be  washed  in  hot  carbolized 
water  after  every  operation,  and  kept  well  coated  with  vasehne  to  pre- 
vent rusting.  Another  objection  is  their  expense,  which,  however,  is,  in 
my  opinion,  more  than  counterbalanced  by  theii*  utility.  I  should  miss 
my  dilator  greatly  in  the  treatment  of  sterihty  and  dysmenorrhea,  as  well 
as  in  intra-uterine  medication.  The  objection  has  been  made  to  two- 
bladed  dilators  that  they  dilate  only  laterally,  and,  therefore,  do  not  give 
the  circular  expansion  which  it  should  be  our  object  to  obtain.  This  is 
true  ;  but  in  the  first  place,  I  do  not  think  it  so  essential  to  have  this  circu- 
lar expansion  ;  secondly,  we  can  obtain  an  expansion  in  every  direction  by 
turning  the  dilator  so  that  it  will  expand  sideways ;  and  lastly,  the  thick- 
ness of  the  united  blade  of  a  three-  or  four-bladed  dilator  would  prevent 
its  use  in  very  many  of  the  cases  where  this  convenient,  rapid  dilatation  is 
most  useful — those  cases  with  long,  conical  cervices,  naiTOw,  and  flexed 
uterine  canals.  If  very  thorough  circvJar  dilatation  is  required,  we  have 
other  means,  still  to  be  described,  at  our  command. 

In  flexions,  it  is  a  good  plan  to  reverse  the  uterine  angle  or  curve,  and 
then  dHate,  thereby  stretching  fibres  which  would  probably  escape  if  the 
abnormal  shape  of  the  uterus  is  not  altered,  and  giving  the  uterine  canal  a 
(at  least  temporary)  different  curve.  In  course  of  time  it  might  restdt  in 
a  compromise  between  the  primary  angle  and  the  reverse,  and  the  normal 
mild  curve  remain.  Besides,  the  ligaments  are  alternately  relaxed  and 
tightened  by  this  maneuvre. 

Sometimes  I  think  it  advisable  to  alternately  expand  and  close  the  di- 
lator, turning  it  as  I  do  so,  thinking  thus  to  get  a  more  uniform  dilatation  of 
the  canaL 

Euhher  Tubes  and  Bags. — The  instruments  of  this  class  consist  of  tubes 
and  bags  of  soft  rubber  of  different  sizes,  which  are  introduced  in  a  col- 
lapsed state  into  the  uterine  canal,  and  there  inflated  with  air  or  water. 
By  introducing  size  after  size,  a  very  thorough  dilatation  may  be  reached 
in  a  short  time.  The  objection  to  all  instruments  of  soft  rubber  is  that  the 
rubber  is  very  liable  to  become  brittle  and  crack  unless  kept  constantly 
moist.  One  may  thus  experience  the  annoyance  of  seeing  one  of  these 
tubes  burst  during  expansion. 

The  most  serviceable  contrivance  of  this  kind  is  that  of  Molesworth, 
which  consists  of  a  series  of  four  rubber  tubes,  the  largest  six  inches  long 
by  one  inch  diameter,  the  smallest  four  and  a  half  inches  long  by  one- 
fourth  of  an  inch  thick.  The  dilating  capacity  of  these  tubes  is  at  least 
double  their  undilated  diameter.  Each  tube  is  provided  with  a  flexible 
central  guiding-rod  of  metal,  by  which  a  curve  to  suit  the  uterine  canal 
can  be  given  it.  The  tube  screws  into  a  hollow  metal  rod  six  inches  long, 
which  again  screws  to  the  nozzle  of  a  metal  syringe,  the  piston-rod  of 
which  is  provided  with  a  screw-catch  at  the  central  end  of  the  barrel,  so 
that  the  piston  can  either  be  propelled  rapidly,  or,  if  the  catch  is  fixed  in 
pins  at  the  barrel,  slowly,  by  simply  screwing  the  piston  down  until  the 
limit  of  dilatation  is  reached.     By  this  contrivance  the  tube  may  be  ex- 


DILATATION    WITHOUT    CUTTING    INSTRUMENTS. 


267 


panded  as  rapidly  or  as  slowly  as  the  operator  may  desire.  An  escape-tube 
of  rubber  guarded  by  a  stopcock  is  attached  to  the  nozzle  of  the  syringe. 

The  manner  of  using  this  dilator  is  the  following  :  The  syringe  is  filled 
with  water,  usually  warm  ;  the  dilating  tube  of  proper  size  is  well  gi'eased, 
the  curve  of  the  uterine  canal  (of  course  previously  ascertained  by  the 
sound  or  probe)  given  it,  and  it  is  screwed  to  the  metal  tube.  Under 
guidance  of  the  finger  the  dilator  is  then  inserted  into  the  cervical  canal 
and  through  the  internal  os,  which  must,  of  course,  be  f>ermeable  to  this 
extent.  The  syringe  is  then  screwed  to  the  tube,  and  the  dilatation 
begun.  In  the  uterine  canal  this  dilatation  should  usually  be  slow  and 
gradual,  that  is,  by  screwing  down  the  piston-rod  in  the  manner  described. 
In  the  vagina,  rectum,  or  when  the  uterus  is  softened  and  easily  dilatable 
(as  in  abortion  or  labor)  more  rapid  dilatation  may  be  exercised  ;  but  the 
dense  unyielding  tissue  of  the  non-gravid  uterus  will  require  more  gradual 
force. 

When  the  limit  of  dilatation  has  been  reached,  the  stopcock  is  turned 
transversely  and  the  reflux  of  water  shut  off.     The   dilator  may  then  be 


Fig.  122.— Molesworth's  Water  Dilator. 

allowed  to  remain  in  utero  for  as  long  a  period  as  appears  desirable  to 
secure  a  permanent  result ;  or,  if  the  object  was  to  dilate  a  rigid  os  during 
labor  until  uterine  contractions  expel  the  tube.  If  it  is  desired  to  inflate 
the  tube  with  more  water  than  the  syringe  holds,  the  stopcock  may  be 
closed  and  the  syringe  refilled  from  the  vessel  through  the  rubber  tubing 
attached.  (This  is  omitted  in  the  diagram.)  On  opening  the  stoj^cock 
again  as  much  more  water  may  be  injected  as  appears  desirable.  The 
capacity  of  the  largest  tube  is  about  one  and  a  half  syringes,  that  of  the 
smaller  tubes  in  proportion.  After  sufficient  dilatation  has  been  accom- 
plished, the  tube  maybe  removed  in  its  dilated  condition,  or,  what  is  pref- 
erable, the  water  is  withdrawn  by  the  syringe  and  ejected  through  the 
side-tube.  A  stopcock  in  the  hollow  metal  tube  would  be  useful,  as  we 
could  then  close  it  and  remove  the  syringe,  leaving  the  dilator  in  place 
as  long  as  desired.  Now  the  stopcock  is  on  the  nozzle  of  the  syringe, 
and  the  latter  can  therefore  not  be  removed  separately  without  allowing 
all  the  water  to  escape  from  the  tube. 

The  one  objection  to  this  instrument  (besides  that  belonging  to  all 
soft-rubber  instruments,  of  drying  and  cracking  when  not  in  use)  is,  that 
the  greatest  expansion  of  the  tubes  is  at  its  middle,  and  that  thei'efore  the 


268  MIlSrOE    GYNECOLOGICAL   MAISTIPULATIOI^S. 

two  ends,  wliich  come  precisely  where  we  want  tlie  most  expansion — at 
the  external  and  internal  os — are  but  little  dilated.  When  dilated  the 
tuloes  have  an  ovoid  shajoe  and  really  only  the  three  middle  inches  of  the 
longest  tube  can  be  said  to  be  thoroughly  dilated.  Now,  in  the  elongated 
cervix  of  pregnancy,  this  deficient  dilatation  of  the  two  ends  of  the  tube 
entails  a  corresponding  want  of  dilatation  of  that  part  of  the  uteiine  canal, 
and  was  the  soui'ce  of  great  annoyance  and  delay  to  me  in  a  case  of  abor- 
tion at  the  third  month.  While  the  cervical  cavity  was  widely  dilated, 
both  the  internal  and  the  external  os,  chiefly  the  latter,  remained  small,  and 
the  greatest  difficulty  was  experienced  in  extracting  the  fetus  and  placenta 
through  it.  Another  objection  is  that  the  flexible  metal  guiding-rod  in 
the  tube  reaches  only  to  within  half  an  inch  of  the  end  of  the  tube,  which 
is  thus  enabled  to  double  over  and  obstruct  its  introduction.  A  third  ob- 
jection is  the  expense  of  the  instrument,  which  of  course  is  enhanced  by 
its  liability  to  spoil  unless  frequently  used.  By  keej)ing  the  tubes  gi-eased 
"with  vaseline,  and  frequently  wetting  and  greasing  the  piston  of  the 
syringe,  the  instruments  may  be  preserved  for  a  long  time. 

In  spite  of  these  objections  I  have  found  Molesworth's  dilator  an  ex- 
ceedingly useful  instrument,  one  I  should  regret  to  miss  in  cases  where 
a  rapid,  easy,  thorough  dilatation  of  an  already  somewhat  patent,  yielding 
canal  is  desired.  It  has  done  me  excellent  service  in  dilating  the  rigid  os 
for  the  exjDulsion  of  the  ovum  or  manual  removal  of  the  placenta  in  abor- 
tion, and  in  the  first  stage  of  labor  ;  in  stricture  of  the  rectum  ;  and  dilat- 
ing the  female  ui-etlu-a.  I  have  no  experience  with  it  in  dilating  the  canal 
of  the  unimpregnated  uterus,  but  should  certainly  expect  equally  good 
service  from  it  in  uterine  polypi  and  fibroids,  and  in  any  case  which  ad- 
mits the  passage  of  the  smallest  tube. 

An  instrument  for  the  same  purpose  has  been  devised  by  Emmet.  Into 
the  lower  edge  of  an  oblong  rubber  bag  enters  a  rubber  tube  with  closed 
end,  which  reaches  to  the  tij)  of  the  bag,  and  through  which  a  stout  flex- 
ible sound  is  passed  as  a  guide,  in  inserting  the  dilator.  The  bag  is  di- 
lated by  water  injected  through  another  tube,  which  has  a  stopcock. 
When  the  bag  is  jDartially  dilated  and  retains  itself,  the  sound  by  which 
it  was  introduced  is  removed,  and  additional  water  may  now  be  injected' 
as  the  case  demands.  Emmet  has  found  this  instrument  useful,  not 
only  for  completing  the  dilatation  begun  by  sponge-tents  or  an  intra- 
uterine tumor,  but  also  for  arresting  hemorrhage  by  direct  j)ressure.  In 
ten  or  fifteen  minutes,  any  necessaiy  dilatation  can  usually  be  effected, 
especially  if  the  parts  have  been  prepared  by  a  sponge  or  other  dilating 
tent,  or  are  soft  and  yielding. 

Of  the  vioHn-shaped  rubber  bags,  known  as  Barnes'  dilators,  it  is 
not  necessary  to  speak  here,  since  they  would  be  of  but  little  service 
in  gynecological  practice,  being  too  large  to  be  introduced  into  a  cervix 
which  is  not  already  pretty  well  dilated.  They  are  especially  intended  for 
obstetrical  cases. 

The  index-finger  can  be  used  to  dilate  the  cervical  canal  when  the  os 
is  sufficiently  patulous  to  permit  the  introduction  of  the  first  joint,  and. 


DILATATIOJSr    WITHOUT    CUTTING    INSTRUMENTS. 


2G9 


tlie  uterine  tissue  is  soft  and  elastic.  "When  tlie  uterus  has  the  density 
and  inelasticity  peculiar  to  the  normal  unimpregnated  organ,  the  finger 
will  scarcely  succeed  in  dilating  it.  In  order  to  accomphsh  digital  dila- 
tation, counter-pressure  on  the  fundus  by  the  other  hand  is  usually  indis- 
pensable. This  dilatation  with  the  finger  comes  into  play  most  frequently 
when  previous  dilatation  by  bougies,  dilators,  or  tents  has  prepared  the 
way,  or  the  canal  has  begun  to  contract  again  after  such  dilatation. 

b.    Gradual  dilatation  [i.e.,  within  twelve  hours)    is  accomplished  by 
porous  substances  shaped  to  fit  the  uterine  canal,  which  gradually  swell 


Fig.    123. — Different  Sizes  of  Sponge  tents. 

through  imbibition  of  the  fluids  from  the  surrounding  tissues.  These  po- 
rous bodies  are  called  uterine  tents.  There  are  a  number  of  substances  from 
which  these  tents  are  made,  those  now  in  use  being  chiefly  sj)onge,  lami- 
naria,  tupelo,  slippery-elm  bark,  elder  and  corn-stalk  pith,  gentian  root. 
Of  these,  only  the  first  three  can  be  said  to  be  universally  popular. 

Sponge -tents. — If  a  piece  of  fine  sponge  is  soaked  in  a  solution  of  gaim- 
arabic,  or  melted  wax,  and  then  rapidly  compressed  to  its  smallest  Hmit, 
it  will  be  found  on  hardening  to  have  become  a  firm  solid  mass.  If  this 
sponge  is  now  placed  where  the  gum-arabic,  or  wax  with  which  it  is  im- 
pregnated, will  dissolve  or  melt,  and  where  fluid  can  be  absorbed  by  the 


270  MINOR    GYI^ECOLOGTCAL    MANIPULATIONS. 

sponge,  the  latter  will  rapidly  swell  and  regain  its  size  before  compression. 
On  this  pi'inciple,  the  sponge  is  used  to  dilate  the  uterine  canal,  the  va- 
gina in  stenosis,  the  rectum  in  stricture,  the  nasal  cavity  for  the  removal 
of  polypi,  and  the  canals  of  wounds  when  the  removal  of  some  body  at  the 
bottom  of  the  narrow  canal  is  desired.  For  use  in  the  canal  of  the  uterus, 
the  sponge  before  compression  is  cut  into  cones  of  different  sizes  and 
length,  and  when  compressed  the  tents  have  the  shape  and  appearance 
presented  in  Fig.  123.  The  compression  is  made  by  winding  cord  tightly 
about  the  moist  sponge,  which  cord  is  removed  when  the  sjDonge  has  hard- 
ened. The  sponge-tents  found  in  the  trade  are  all  made  in  this  manner. 
The  surface  of  the  tent  is  rendered  smooth  by  sand-papering,  and  many 
tents  are  coated,  besides,  with  a  thin  film  of  wax,  or  gum-arabic,  which 
renders  them  more  easy  of  introduction.  Thi-ough  the  base  of  the  tent  a 
stout  cord  is  passed,  b}^  which  it  can  be  withdrawn.  The  conical  shape 
of  the  sponge-tents  ordinarily  sold  is  objectionable  for  the  reason  that  the 
tapering  portion  of  the  tent  usually  lies  precisely  where  the  most  expan- 
sion is  desired,  viz.,  at  the  internal  os.  I  have  therefore  generally  cut  off 
half  an  inch  or  more  of  the  tip  of  the  tent,  and  thus  secui-ed  more  com- 
plete distention  at  the  narrowest  portion  of  the  canal.  Dr.  Albert  H. 
Smith,  of  Philadelphia,  has  his  tents  made  cylindrical,  instead  of  conical. 
They  are  less  easy  to  introduce,  it  is  true  ;  but  this  objection  must  be  met 
by  previous  dilatation  by  one  of  the  rapid  dilators  already  described. 

There  are  many  sizes  of  sponge-tents  furnished,  varying  from  that  of  a 
knitting-needle,  to  that  of  the  middle  finger,  and  from  two  to  four  inches 
in  length.  The  dilating  capacity  of  these  tents  is  about  twice  their  com- 
pressed size  (two  hundred  per  cent.). 

It  is  now  so  easy  to  procure  any  size  and  number  of  sponge-tents  at 
the  instrument-mahers'  or  druggists',  tents  which  are  much  neater  and 
smoother  than  the  amateur  can  make  them,  unless  much  trouble  be  taken, 
that  it  is  scarcely  necessary  for  a  physician,  living  within  easy  distance  by 
mail  of  any  city,  to  know  how  to  make  them  himself.  The  brief  directions 
given  above  will,  however,  enable  him  to  do  so,  should  a  sudden  emer- 
gency arise,  and  no  tents  be  at  hand.  Dr.  Beverly  Cole,  of  San  Francisco, 
has  shown  a  very  rapid  way  of  making  compressed  sponge,  by  simply 
dipping  a  suitable  piece  of  sponge  in  melted  wax  (which  can  be  had 
anywhere),  placing  the  hot  waxed  sj)onge  between  two  sheets  of  bibulous 
paper,  laying  it  on  the  floor,  or  a  hard  chair,  with  a  book  over  it,  and 
standing  or  sitting  on  the  book  for  a  few  minutes,  until  the  wax  has  had 
time  to  harden.  The  amount  of  compression  will  naturally  depend  greatly 
on  the  weight  of  the  individual.  The  flat  compressed  sponge  can  then  be 
cut  with  a  pocket-knife  into  any  desired  shape. 

An  objection  to  this  thorough  impregnation  with  wax  is  that  it  takes 
rather  a  higher  temperature  to  melt  the  wax  than  the  body  affords,  and 
that  the  imbibition  and  expansion  of  the  sponge  is  not  quite  as  thorough, 
perhaps,  as  when  a  soluble  ingredient  is  used. 

Some  gynecologists  have  given  the  tents  a  curved  shape,  to  conform  to 
the  direction  of  the  uterine  canal,  and  doubtless  it  is  easier  to  introduce 


DILATATION    WITHOUT    CUTTING    INSTRUMENTS.  271 

such  a  curved  tent  through  a  flexed  canaL  "When  the  tent  swells,  it  be- 
comes straight,  and  thus  acts  quite  as  well  in  straightening  the  uterus  as 
the  straight  tents. 

Professor  EUerslie  Wallace,  of  Philadelphia,  has  inserted  a  slender  watch- 
spring  in  the  curved  tent,  giving  the  spring  the  opposite  curve  to  that  of 
the  sponge,  and  uses  this  contrivance  to  straighten  a  retrodisplaced  and 
slightly  adherent  uterus.  When  the  sponge  swells,  the  sijring  begins  to 
act  and  draws  the  fijndus  uteri  up,  and  thus  stretches  the  adhesions.  The 
idea  certainly  seems  very  plausible,  but  I  have  no  experience  with  the 
method. 

The  rapidity  with  which  the  sponge  swells  is  so  great  that  no  time 
should  be  lost  in  inserting  it  into  the  uterus,  since  a  moment's  delay  after 
it  has  touched  the  moist  cervical  canal  results  in  a  roughening  of  the  sur- 
face of  the  sponge,  and  difficulty  or  inability  to  complete  the  maneu\Te. 
The  sponge  has  generally  reached  the  limit  of  expansion  within  an  hour 
from  the  time  of  its  introduction.  But  it  should  be  left  in  the  uterus  for 
several  hours  after  its  expansion  in  order  to  produce  a  permanent  eifect. 

The  peculiar  formation  of  the  sponge,  the  multitude  of  small  alveoli 
scattered  through  it,  greatly  favors  the  admission  of  air  and  the  decompo- 


FiG.  124.  —Smith's  Forceps  for  Introducing  and  Removing  Tents. 

sition  of  the  secretions  absorbed  into  the  sponge  from  the  surrounding 
tissues.  The  absorption  of  these  putrid  secretions  by  the  neighboring 
blood-vessels  and  lymphatics  is  followed  by  local  inflammation  and  per- 
haps general  septic  infection.  To  prevent  this  decomposition,  sponge-tents 
are  now  always  impregnated  with  some  disinfectant,  usually  carbolic  acid. 
Lawson  Tait  has  them  soaked  in  oil  of  cloves,  Aveling  in  a  solution  of 
permanganate  of  potash.  A.  H.  Smith  prefers  powdered  saHcyhc  acid,  the 
sponge  first  being  coated  with  soap.  The  carbolic  seems  to  me  the  best 
But  none  of  these  preventives  are  certain  against  infection. 

Manner  of  Introduction. — A  sponge-tent  may  be  introduced  either  with 
or  without  a  speculum.  It  may  be  seized  in  the  long  dressing-forceps,  or 
it  is  mounted  on  a  stylet  slightly  curved  like  a  sound,  and  is  carried  up  to 
the  cervix  and  its  point  inserted  in  the  external  os.  By  means  of  the 
forceps  or  stylet  the  sponge  is  firmly  pushed  into  and  through  the  cer- 
vical canal,  being  aided  by  pressure  over  the  fundus  with  the  outer  hand 
if  no  speculum  is  used,  or  by  steadying  the  cervix  with  a  tenaculum 
if  the  operation  is  done  through  a  speculum.  Dr.  A.  H.  Smith  uses 
a  stout  forceps  (Fig.  124)  for  introducing  sponge-tents,  which  he  gen- 
erally does  without  the  speculum,  with  the  patient  on  the  back. 

I  have  never  tried  to  introduce  a  sponge-tent  without  a  speculum, 
fearino'    that   the   inevitable    contact  with   the  vaginal  secretions  would 


272 


MINOR    GYISTECOLOGICAL    MAjSTIPULATIOjS'S. 


rouglien  the  siu-face  of  tlie  sponge,  and  interfere  witli  its  passage,  and 
finding  the  operation  often  quite  difficidt  enough  when  the  os  was  ex- 
posed. Still,  when  the  os  is  patulous  and  the  canal  tolerably  wide,  I  do 
not  doubt  the  feasibility  of  introducing  a  sponge-tent  in  this  manner.  The 
crowding  down  of  the  fundus  uteri  over  the  tent  is  the  one  point  of  this 
method. 

A  large  and  short  cylindrical  and  a  valve  speculum  may  give  space 
enough  to  insert  the  tent,  if  the  canal  is  not  flexed  find  of  fair  width. 

I  prefer  the  Sims  and  perform  the 
maneuvre  in  the  following  manner : 
Having  exposed  the  cervix,  I  seize 
the  anterior  lip  with  the  tenaculum, 
draw  down  and  straighten  the  ute- 
rus. The  tent  is  then  impaled  on 
the  stylet  (every  tent  has  a  small  hole 
in  its  base  for  the  purpose),  or  is 
grasped  in  the  long  forceps,  and  is 
rajDidly  dipped  in  an  open  bottle  of 
pure  carbolic  acid  as  an  additional 
safeguard  against  decomposition.  It 
is  then  quickly  buried  in  a  pofc  of 
vaseline  and  without  a  moment's 
hesitation  inserted  into  the  os  and 
pushed  forward  in  the  direction  of 
the  internal  os.  No  time  must  be 
lost  in  these  several  steps,  else  the 
surface  of  the  tent  will  become 
rough  from  the  carbolic  acid,  and  a 
new  tent  will  have  to  be  substituted. 
When  the  tent  has  been  forced  up 
through  the  internal  os  and  its  base 
projects  but  slightly  from  the  ex- 
ternal OS,  it  is  held  for  a  minute  or 
two  to  give  its  point  the  opportunity  to  swell  and  thus  insure  its  retention  ; 
the  slide  is  pushed  down  and  the  stylet  withdrawn.  If  the  force j)S  are 
used  to  carry  the  tent,  care  should  be  taken  not  to  twist  the  twine  attached 
to  the  tent  into  the  forceps-blades  ;  else,  on  removing  the  instrument,  the 
tent  may  also  be  accidentally  dislodged.  The  vagina  is  now  cleansed  of 
any  secretions  (blood  or  mucus),  and  several  carbolized  flat  glycerine  tam- 
pons are  placed  over  the  cervix  to  insure  retention  of  the  tent  and  prevent 
the  escape  of  discharges.  The  patient  is  placed  in  bed  and  kept  there 
until  after  the  removal  of  the  tent.  The  expansion  of  the  tent  soon  gives 
pain,  and  I  therefore  always  leave  a  prescription  for  several  morphine  sup- 
positories of  one-fourth  to  one-half  a  gTain  each,  to  be  taken  according  to 
the  amount  of  pain,  and  direct  that  hot  applications  be  made  to  the  ab- 
domen and  a  hot  bottle  be  kept  at  the  feet. 

It  is  a  matter  of  some  importance  in  choosing  the  size  of  tent  to  be 


Fig.  125.— Introduction  of  Tents  through  Sims' 
Speculum  (P.  F.  M.). 


DILATATIOIS"    WITHOUT    CUTTING    IXSTRUMENTS.  273 

introducecl,  not  to  take  too  large  a  one,  'wliicli  may  need  to  be  crowded 
into  tlie  uterine  canal.  As  a  rule  the  tent  will  then  catch  at  the  internal 
OS  and  become  so  rough  and  swollen  during  the  fruitless  attempts  to  force 
it  in,  as  to  be  worthless.  The  only  thing  to  do  in  such  a  case  is  to  throw 
the  old  tent  away  and  do  what  should  have  been  done  at  first,  select  a 
smaller  one,  which  will  easily  pass  through  the  internal  os.  I  have  re- 
peatedly made  this  mistake,  hoping  to  accomplish  a  thorough  dilatation 
in  one  sitting,  but  have  been  obliged  to  desist  and  content  myself  with  a 
moderate  dilatation,  following  it  up  later  with  some  other  method.  Be- 
sides the  annoyance  of  failing  in  the  attempt  and  giving  the  j)atient 
unnecessary  pain,  the  inevitable  lacerations  of  the  cervical  mucous  mem- 
brane through  the  tearing  out  of  the  tenaculum  open  channels  to  septic 
infection.  Occasionally  the  rapid  dilatation  of  the  internal  os  with  a  steel 
two-bladed  dilator  will  permit  the  introduction  of  the  tent. 

Care  should  always  be  taken  not  to  push  the  tent  in  so  deeply  as  to 
bury  its  base  within  the  os.  If  this  be  done,  when  the  tent  swells  the  ex- 
ternal OS  closes  over  it,  and  it  will  be  found  exceedingly  difficult  to  force 
the  enlarged  and  rough  surfaced  sponge  through  the  narrow  orifice  when 
it  is  seized  by  the  forcejDS  or  string  with  a  view  to  removal. 

If  a  stylet  is  used  to  introduce  the  tent,  it  might  readily  occur  that 
considerable  force  in  j)ushing  up  the  sponge  might  thrust  the  point  of  the 
stylet  through  the  whole  length  of  the  tent  and  injure  the  uterus. 

No  sponge-tent  should  be  allowed  to  remain  longer  than  twelve  hours, 
and  less  will  usually  suffice.  It  is  therefore  a  good  plan  to  introduce  the 
tent  early  in  the  morning  and  remove  it  on  the  same  day  toward  evening. 
If  introduced  in  the  afternoon,  eighteen  or  twenty  hours  may  elapse  be- 
fore the  physician  can  again  see  the  patient  and  remove  it,  and  that  might 
be  too  long.  Except  where  a  very  decided  alterative  and  stimulant  eifect 
is  desired,  it  is  better  to  remove  the  tent  before  the  twelve  hours  are  up 
than  to  prolong  the  interval.  Dr.  A.  H.  Smith,  in  this  respect,  follows  an 
entirely  difterent  plan  from  that  generally  employed  ;  he  leaves  the  sponge- 
tent  in  utero  for  forty-eight  hours,  claiming  that  its  removal  after  twelve 
to  twenty-four  hours  produces  abrasion  of  the  endometrium  and  hem- 
orrhage, while  after  a  longer  period  the  uterus  is  paralyzed,  the  sponge 
becomes  loosened  and  is  easily  detached.  I  cannot  judge  of  this  practice 
•from  personal  experience,  but  think  it,  theoretically,  very  good  ;  practically, 
I  should  fear  septic  infection. 

As  already  stated,  the  patient  has  not  left  her  bed  since  the  insertion 
of  the  tent.  When  the  time  has  arrived  to  remove  it,  I  again  jDlace  the 
patient  in  Sims'  position,  expose  the  cervix  with  Sims'  speculum,  remove 
the  tampons,  and  seizing  the  sponge  firmly  with  the  dressing-forceps  give 
it  a  slight  rotary  motion  to  dislodge  it,  and  then  draw  on  it  steadily  and 
forcibly.  The  uterus  is  thereby  forcibly  drawn  down,  and  to  steady  it  I 
place  two  fingers  of  my  left  hand  on  either  lip  of  the  cervix,  or  encu'cle  the 
cervix  with  the  loop  of  the  depressor.  A  very  convenient  instniment  for 
this  purpose  has  been  devised  by  Sass.  Considerable  force  is  often  required 
to  remove  a  sponge-tent,  in  consequence  of  the  intimate  relations  between 
18 


274  MINOE    GYNECOLOGICAL    MANIPCLATIONS. 

the  minute  surface  particles  of  the  sponge  and  the  inequalities  of  the 
mucous  membrane.  The  resvilt  is  that  the  membrane  is  generally  con- 
siderably torn  and  excoriated,  and  it  may  even  be  removed  almost  in 
toto.  This  property  of  the  sponge  dilator  has  been  used  as  a  therapeu- 
tic agent  in  hyperplastic  endotraehelitis  and  enlargement  of  the  Na- 
bothian  glands,  which  are  torn  off,  as  by  a  curette,  when  the  sponge  is 
removed. 

The  withdrawal  of  the  sponge  leaves  a  gaping  bleeding  cavity,  which 
should  be  washed  out  with  a  carbolized  solution  or  mopped  out  with  an 
apjDlicator  and  cotton  soaked  in  carbolized  glycerine.  The  procedure  for 
which  the  canal  was  dilated  (digital  examination  of  the  uterine  cavity, 
intra-uterine  application,  curetting  of  the  cavity,  division  of  the  capsule 
of  a  fibroid  tumor,  removal  of  a  polypus),  may  then  be  at  once  under- 
taken ;  or,  if  the  sponge  was  introduced  as  a  therapeutic  measure  in  itself, 
nothing  further  is  done.  The  uterine  cavity  and  vagina  having  been 
thoroughly  cleansed  and  disinfected,  carbolized  glycerine  tampons  are 
again  introduced  if  a  watery  drain  is  desired,  and  the  patient  is  again  put 


Fig.  126. — Sass'  Counter-pressure  Loop  for  Removal  of  Dilated  Tents. 

to  bed,  where  prudence  dictates  that  she  should  stay  for  at  least  another 
twenty-four  hours.  The  dangerous  results  of  the  sponge-tent  usually 
follow  within  twenty-four  hours  after  its  removal ;  due  caution  should 
therefore  be  exercised  by  the  physician  and  impressed  upon  the  patient. 
All  exposure  to  cold  and  excitement  for  several  days  should  be  carefully 
avoided,  and  frequent  cleansing  injections  should  be  employed. 

An  anesthetic  is  seldom  needed  either  for  the  introduction  or  removal 
of  the  tent.  But  an  opiate  is  usually  required  during  the  dilating  period. 
Abdominal  pain,  of  a  grinding,  expulsive  nature,  is  usually  felt,  in  pro- 
portion to  the  size  of  the  sponge  and  the  elasticity  of  the  tissues,  and  I 
have  even  seen  nausea  and  vomiting  (reflex),  chills,  and  slight  collapse 
occur  at  the  height  of  the  distention.  Such  symptoms  need  not  in  them- 
selves alarm  the  physician  ;  but  if  the  patient  should  have  repeated  chills, 
or  the  pain  resist  a  fair  quantity  of  opium  (best  given  in  suppositories), 
the  immediate  removal  of  the  tent  is  called  for,  especially  as  the  severity 
of  these  symptoms  shows  that  it  has  done  its  duty,  so  far,  at  least,  as  dila- 
tation is  concerned.  If  it  is  intended  to  perform  some  of  the  operations 
above  mentioned  immediately  after  removing  the  tent,  it  is  advisable  to 
anesthetize  the  patient  before  proceeding  to  remove  it,  in  order  to  have  no 
delay  afterward. 

A  tent  should  always  be  introduced  at  the  house  of  the  patient,  never  in 
the  physician's  office.  The  latter  practice,  although  frequently  followed, 
is  always  hazardous,  and  any  accidents  which  chance  to  ensue  should 
very  properly  be  laid  to  the  fault  of  the  physician.     It  is  little  short   of 


DILATATION"    WITHOUT    CUTTING    INSTRUMENTS. 


275 


criminal  carelessness  and  audacity  to  trifle  in  this  manner  with  so  dan- 
gerous an  instrument  as  the  sponge-tent,  or,  for  that  matter,  any  dilating 
tent. 

Quite  as  important  as  this  rule  is  that,  not  to  follow  one  sponge-tent 
immediately  by  another.  It  has  been  stated  that  in  removing  the  tent 
more  or  less  uterine  mucous  membrane  is  removed  with  it,  and  that  there- 
fore a  raw,  abraded  surface  remains.  Now,  it  is 
a  matter  of  experience  that  a  freshly  denuded 
surface  absorbs  septic  germs  much  more  rapidly 
than  one  covered  Avith  granulations.  And  this 
is  the  reason  why  it  is  always  advisable  to  wait  a 
few  days  until  granulations  have  formed  in  the 
cervix  before  repeating  the  tent.  If  immediate 
dilatation  is  still  required  the  finger  may  be 
tried,  or  a  steel  or  sound-dilator,  or  one  of  the 
non-infecting  gradual  dilators  (laminaria  and 
tupelo),  yet  to  be  described,  should  be  inserted. 
For  this  same  reason  a  sponge-tent  should  never 
be  employed  immediately  after  a  cutting  opera- 
tion on  the  cervix  or  uterine  body.  I  am  aware 
that  this  rule  has  often  been  violated,  but  its 
violation  has  cost  a  certain  number  of  victims, 
and  the  profession  are  now  of  one  accord  in  con- 
demning the  repeated  introduction  of  sponge- 
tents.  Some  authors  even  go  so  far  as  to  pro- 
scribe them  entirely.  This,  I  think,  is  going  a 
little  too  far.  Deaths  from  a  single  sponge-tent 
have  been  reported  by  Thomas,  GoodeU,  01s- 
hausen,  Hildebrand,  Winckel,  Aitken,  Lusk,  Jan- 
vrin,  and  quite  a  number  of  others.  Only  re- 
cently a  physician  of  this  city  (a  speciaHst)  lost  a  patient  by  metro-perito- 
nitis, which  came  on  immediately  after  the  removal  of  a  sponge-tent.  That 
such  accidents  can  happen  to  experts  proves  only  that  the  agent  is  a  dan- 
gerous one,  and  that  every  possible  precaution  should  be  taken  when  cir- 
cumstances compel  its  employment.  When  another  agent  will  do  as  well, 
it  certainly  is  far  safer  not  to  choose  the  sponge. 

To  avoid  this  danger  of  septic  infection,  several  ingenious  contrivances 
have  been  proposed.  Thus,  the  tent  is  enveloped  in  goldbeater's  skin,  the 
base  being  left  uncovered.  When  introduced  the  base  projects  from  the 
OS,  and  the  sponge  is  expanded  by  water  injected  into  the  vagina,  and  by 
glycerine  and  water  tampons  placed  over  the  cervix.  Or  the  whole  tent 
is  covered,  fluid  being  admitted  to  the  tent  through  minute  holes  pricked 
in  the  skin  at  the  base.  Or  thin  gutta-percha  or  rubber  cloth  is  used  in- 
stead of  the  goldbeater's  skin.  Emmet  has  constructed  a  sponge-dilator 
shown  in  Fig.  127.  "Through  a  disk  of  hard  rubber  passes  a  brass  tube, 
which  is  pei'forated  by  a  number  of  small  holes,  and  open  at  each  extrem- 
ity.    This  tube  is  passed  through   the  centre  of  a  sponge-tent  of  suit- 


FiG.  127. — Emmet's  Spor.ge 
Dilator. 


276  MI]S^OR    GYNECOLOGICAL    MANIPULATIONS. 

able  size,  the  wliole  being  covered  by  a  thin  india-rubber  cot  or  bag,  of 
w'hicli  the  mouth  is  stretched  over  the  edges  of  the  disk,  and  the  free  edge 
of  the  cot,  which  has  been  drawn  over  the  disk,  is  then  secured  between 
the  under  side  of  the  disk  and  the  brass  j)late.  The  plate  has  attached  to 
it,  on  one  side,  a  knob  which  can  be  grasped  by  a  pair  of  forceps,  the  blades 
of  which  are  closed  by  sliding  forward  the  canula.  When  the  knob  is  held 
by  the  forceps,  a  ball-and-socket  joint  is  formed,  which  will  admit  of  mo- 
tion in  any  direction.  Over  the  bulb  is  slipped  a  j)iece  of  india-rubber 
tubing,  a  foot  or  more  in  length,  through  which  water  is  introduced  for 
swelling  up  the  tent,  and  at  tbe  end  of  the  tube  is  a  stoj)COck.  To  the 
otlier  side  of  the  stopcock  a  Davidson  syringe  may  be  attached,  or,  what  is 
better,  a  thin  india-rubber  bag,  such  as  are  used  for  pessaries,  with  tube 
and  stopcock.  The  dilator  is  introduced  by  steadying  the  cervix  with  a 
tenaculum  in  one  hand,  and  by  holding  the  forceps  and  tubing  in  the 
other  hand,  the  proper  direction  can  be  given  to  the  instrument.  When 
it  has  been  introduced  within  the  canal  to  the  proper  depth,  a  small 
amount  of  water  is  to  be  thrown  in  before  removing  the  forceps.  As  the 
tube  in  the  centre  of  the  sponge  is  open  at  its  extremity  and  its  sides  jdcx'- 
forated,  the  water  will  make  its  exit  at  the  upper  portion,  and  dilatation 
will  extend  from  above  downward,  so  that  the  instrument  cannot  shp  out. 
The  sponge  is  sufficiently  dilated  in  a  few  moments  to  cause  it  to  be  re- 
tained, and  the  forceps  may  then  be  removed  by  sliding  back  the  canula. 
The  patient  is  told  to  lie  on  her  back  in  bed,  and  to  place  on  her  abdomen 
an  air-bag  containing  water,  which  is  made  to  flow  into  the  dilator  by  oc- 
casionally compressing  the  bag  with  the  hands.'"'  The  dilator  is  generally 
retained  twelve  hours,  unless  more  rapid  dilatation  is  desired.  By  open- 
ing the  stopcock  the  water  is  drained  off  from  the  sponge,  and  the  dilator 
is  then  withurawn  by  seizing  it  with  forceps  by  the  knob,  and  pushing 
back  the  utei-us  with  the  finger  of  the  other  hand.  The  disadvantage  of 
this  instrument  is  that  it  requires  an  already  moderately  dilated  canal  to 
allow  its  introduction. 

These  contrivances  certainly  look  very  useful  and  plausible  ;  but  I  do 
not  believe  they  have  become  jDopular  as  yet,  chiefly  because  we  have  of 
late  obtained  a  substitute  for  the  sjDonge  in  the  tupelo-root,  to  be  de- 
scribed presently. 

The  counter-indications  to  the  use  of  sponge-tents  are  therefore  such 
as  are  common  to  all  ajDj^hcations  to  the  uterus,  viz.,  acute,  subacute,  or 
recent  chronic  inflammatory  conditions  of  the  uterus  or  adnexa,  and  'pve.g- 
nancy  ;  and  such  as  are  special  to  sj)onge-tents,  viz.  :  a  fresh  wound  or  raw 
surface  in  the  endometrium,  and  a  hyperemic,  readily  absorbent  condition 
of  the  tissues,  as  during  abortion. 

The  dangers  arising  from  the  use  of  sponge-tents  in  any  case  have  al- 
ready been  referred  to,  viz.  :  metro-peritonitis,  cellulitis,  septic  infection, 
and  death.  Considering  the  recklessness  with  which  this  agent  has  been 
employed  for  many  years,  and  its  universal  use  by  general  practitioners 
and  all  who  dabble  in  gj'necology,  it  is  greatly  to  be  wondered  that  the 
accidents  and  deaths  from   it  have  not  been  more  frequent.     Sui'ely,  a 


DILATATION    WITHOUT    CUTTING   INSTRUMENTS.  277 

special  Providence  reigns  over  the  female  sex  in  this  as  in  very  many  other 
manipulations  to  which  their  reproductive  organs  are  subjected !  Be  it 
understood,  then,  that  it  is  not  the  dilating  property  of  the  sponge-tent 
which  is  dangerous,  but  the  decomposition  of  the  fluids  it  has  imbibed,  and 
their  absorption  through  the  abraded  surface  left  after  the  removal  of  the 
tent.  The  j)eculiar  porous  character  of  the  sponge  favors  both  this  decom- 
position and  the  abrasion  in  a  far  greater  degree  than  the  other  absorbent 
dilators. 

The  precautions  to  be  observed,  therefore,  in  using  sponge-tents  are  : 
1,  always  to  introduce  them  at  the  house  of  the  patient,  and  keep  her  in 
bed  while  the  tent  is  retained,  and  for  at  least  twenty-four  hours  after  ;  2, 
never  to  insert  a  second  sponge-tent  immediately  after  the  first,  but  adopt 
other  means  of  increasing  the  dilatation,  if  it  is  still  needed,  or  defer  the 
second  tent  for  several  days  until  granulations  have  formed  in  the  endo- 
metrium ;  3,  never  to  introduce  a  sponge-tent  against  a  freshly  wounded 
surface,  as  after  discission  of  the  external  or  internal  os,  or  oiaerations  in 
the  uterine  cavity  ;  4,  never  to  use  a  sponge-tent  when  there  is  evidence 
of  previous  inflammation  in  or  about  the  uterus,  or  pregnancy  exists  or  is 
suspected,  or  an  abortion  is  in  progress  or  has  recently  taken  place  ;  5, 
never  to  leave  a  sponge-tent  in  the  uterus  longer  than  twelve  hours  ;  6, 
always  to  disinfect  the  tent  thoroughly  immediately  before  inserting  it, 
and  the  vagina  and  uterine  cavity  after  its  removal ;  7,  to  use  a  tent 
which  -will  readily  pass  through  the  internal  os  at  the  first  attempt ;  8,  to 
treat  the  procedure  as  an  operation,  possibly  productive  of  serious  conse- 
quences. 

Laminaria  Tents. — These  tents  were  introduced  into  practice  by  Sir 
James  Simpson,  G.  J.  "Wilson,  and  Carl  Brauu,  about  the  year  1863, 
and  are  made  from  the  root  of  the  laminaria  digitata,  or  sea-tangle,  by  re- 
moving the  bark  and  turning  them  on  a  lathe  until  their  surface  is  entirely 
smooth  and  uniform.  They  come  in  sizes  varying  from  that  of  a  knitting- 
needle  to  that  of  a  lead-pencil,  laminaria  tents  of  a  larger  size  than  the 
latter  being  rare  because  the  plant  seldom  grows  thicker.  The  tents  are 
made  about  two  inches  long,  rounded  at  either  end,  and  of  uniform  thick- 
ness throughout,  not  conical  like  the  sponge-tents.  They  come  either 
solid,  or  perforated  through  their  length,  a  modification  recommended  by 
Greenhalgh  in  order  to  increase  their  sm-face  of  absorption  and  thereby 
their  expansion.  Through  one  end  of  the  tent  is  drilled  a  hole,  in  which 
a  cord  is  fastened  for  the  removal  of  the  tent.  The  best  laminaria  tents 
come  from  England. 

The  material  is  exceedingly  hard  and  almost  incapable  of  being  cut  by 
a  knife,  I  have  broken  the  blade  of  my  pocketknife  in  the  attempt  to 
whittle  down  a  laminaria  tent.  A  file  alone  v>-ill  make  an  impression. 
This  exceeding  density  entails  a  comparatively  slow  and  limited  absorption 
and  expansion,  as  compared  wnth  the  sponge-tent.  While  the  latter  will 
dilate  within  a  few  minutes  almost  to  three  times  its  compressed  size,  the 
laminaria  will  barely  double  its  diameter  in  the  course  of  several  hours. 
According  to  experiments  made  by  Cohn,  a  laminaria  tent,  55  mm.  long, 


278  MIIiTOR    GYJN'ECOLOGICAL    MANIPULATIOIN'S. 

increased  in  length  by  only  6  mm.  in  twenty-four  hours,  but  expanded 
from  24  mm.  to  42  mm.  The  inci'ease  in  length  is,  therefore,  but  slight, 
that  in  thickness  not  quite  one  hundred  per  cent.  In  accordance  with 
the  density  of  the  laminaria  and  its  slowness  of  expansion,  is  the  force 
with  which  it  expands.  Matthews  Duncan  states  that  his  experiments 
show  that  the  laminaria  expands  with  a  force  of  five  hundred  to  six 
hundred  pounds  to  the  square  inch.  The  walls  of  a  uterine  canal, 
therefore,  which  would  yield  but  little  to  a  sponge-tent,  will  be  slowly 
but  steadily  forced  apart  by  the  laminaria.  The  peculiar  imbibition  and 
softening  of  the  tissues  produced  by  the  sponge  is,  however,  much  less 
marked  with  laminaria.  The  action  of  the  sponge  is,  therefore,  although 
more  rapid,  rather  less  painful  and  forcible  than  that  of  the  laminaria. 
The  soft,  succulent  tissues  dilate  more  easily. 

The  hollow  laminaria  tents  swell  more  rapidly  and  thoroughly  than 
the  solid  ones,  but  not  as  forcibly,  because  the  thin  walls  are  easily  com- 
pressed by  the  dense  uterine  canal.  It  is,  therefore,  questionable  whether 
the  perforation  of  the  tent  is  really  an  improvement.  The  greater  expan- 
sion is  more  or  less  outweighed  by  a  diminution  of  resistance  and  increased 
compressibility. 

The  limited  size  of  the  laminaria  tents,  the  largest  when  fully  expanded 
not  exceeding  the  thickness  of  the  little  finger,  is  an  objection  which  can 
be  overcome  by  inserting  several  tents  side  by  side,  one  after  the  other, 
or  a  bunch  of  small  tents  held  together  by  a  rubber  band.  This  is  ex- 
ceedingly plausible  in  theory,  but  by  no  means  so  easily  carried  out,  as 
any  one  will  confirm  who  has  tried  to  introduce  a  second  tent  beside  the 
first,  which  is  constantly  slipping  out  of  the  cervix  as  soon  as  the  pressure 
upon  it  by  forceps  or  tent-applicator  is  removed.  And  to  introduce  a 
bunch  of  tents  requires  a  patulous  canal,  free  from  rugse  and  pockets,  in 
every  one  of  which  the  point  of  one  of  the  tents  is  liable  to  catch.  How- 
ever, practice  makes  perfect,  and  Atthill  constantly  applies  tents  in  this 
manner,  and  is  very  well  satisfied  with  it. 

The  laminaria  tent,  being  constructed  from  a  salt-water  plant,  contains 
a  large  quantity  of  salt,  which  is  distinctly  recognizable  by  the  taste.  When 
a  laminaria  tent  is  expanded,  its  smooth  cylindrical  sui-face  is  lost,  and  it 
becomes  rough,  with  sharp  edges  extending  along  its  long  diameter,  and 
appears  twisted  on  itself  (Fig.  129).  This  is  due  to  the  peculiar  twisted 
condition  of  the  fibres  of  the  plant,  which  is  not  ajDparent  when  the  sur- 
face is  smoothly  turned.  Curiously,  when  the  rough,  unjDolished  root  is 
swelled  in  water,  its  surface  becomes  round  and  smooth,  because  the  in- 
equalities in  the  surface  are  equalized  by  the  swelling.  When  it  is  turned 
these  compensating  inequalities  are  removed,  and  therefore  the  surface 
becomes  rough. 

A  laminaria  tent  is  very  liable  to  expand  unequally  in  the  uterine  cav- 
ity, the  portions  in  the  cervical  canal  and  uterine  cavity  proper  swelling 
to  their  utmost  limit,  and  the  spot  corresponding  to  the  narrow  internal 
OS  remaining  comparatively  unexpanded.  The  tent  then  assumes  the  shape 
of  the  cervical  and  uterine  cavity,  as  shown  in  Fig.  130.     Naturally  the 


DILATATION    WITHOUT    CUTTING   INSTRUMENTS. 


279 


removal  of  a  tent  expanded  in  this  manner  is  difficult,  because  the  ex- 
panded upper  part  of  the  tent  must  be  forcibly  drawn  through  the  narrow 
internal  os,  as  shown  by  the  unexpanded  isthmus.  Besides,  if  the  tent 
should  have  been  inserted  entirely  within  the  external  os,  which  it  is  often 
necessary  to  do  to  prevent  its  slipping  out  before  a  tampon  can  be  applied 
to  retain  it,  the  external  os  will  close  over  the  tent,  and  further  difficulty 
be  experienced  in  obtaining  a  firm  grasp  and  removing  it. 


^ 


Fig.  128.— Laminaria  Tents, 
Straight  and  Curved  (P.  F.  M.). 


Fig.  129.— Laminaria  Tent 
Dilated  in  Water  (P.  F.  M.). 


Fig.  130. — ^Laminaria  Tent 
Dilated  in  TJtero,  showing 
Constriction  by  Internal  Os 
(P.  F.  M.). 


By  placing  a  laminaria  tent  in  warm  water  for  a  few  minutes  it  be- 
comes sHghtly  softer  and  can  be  bent  so  as  to  conform  to  the  natural  cui-Ve 
of  the  uterine  canal,  retaining  the  shape  when  hard.  This  curve  often 
greatly  faciHtates  its  introduction. 

Maimer  of  Introduction. — A  laminaria  tent  may  be  introduced  in  veiy 
much  the  same  manner  as  a  sponge-tent,  either  on  the  finger  or  through 
a  speculum.  The  speculum  is  always  advisable,  because  a  tampon  is  at 
once  required  over  the  cervix  to  retain  the  tent.  If  the  tent  is  hollow  it 
may  be  impaled  on  a  Sims  thick  slide-applicator,  or  stout  metal  applicator, 
if  solid,  it  is  seized  in  the  forceps  and  carried  into  the  uterine  canal.  The 
outer  hand  will  greatly  aid  the  passage  through  the  internal  os.  It  is,  as 
a  rule,  much  easier  to  introduce  a  laminaria  than  a  sponge  tent,  because 


280  MIN'OR    GYNECOLOGICAL    MANIPULATIONS. 

its  smooth  surface  and  slow  absoi-ptioD  and  its  uniform  size  offer  no  ob- 
stacles. But  this  very  smoothness  renders  the  retention  of  the  tent  more 
difficult,  and  it  often  requires  quite  a  deal  of  trouble  and  ingenuity  to 
retain  the  tent  until  a  tamj)on  can  be  placed  over  the  os.  By  holding  it 
"within  the  external  os  with  the  forceps  or  the  left  index-finger,  until  the 
tampon  can  be  seized  and  placed  over  the  cervix,  or  a  second  tent  can 
be  grasped  and  passed  beside  the  first,  and  then  securing  both  with  the 
index  or  forceps,  and  so  on,  this  annoying  ghding  out  of  the  tents  may 
be  avoided.  It  is  not  advisable  to  push  the  tents  up  to  the  fundus  and 
thus  insure  their  retention,  because  it  would  probably  be  very  difficult  to 
remove  them  after  expansion,  and  the  uterine  cavity  would  be  unneces- 
sarily irritated.  It  is  the  uterine  canal,  up  to  a  short  distance  above  the 
internal  os,  which  we  wish  to  dilate,  not  the  region  of  the  orifices  of  the 
Fallopian  tubes. 

If  there  is  any  obstruction  at  the  internal  os,  the  cervix,  which  of 
course  has  all  along  been  steadied  with  the  tenaculum  in  the  anterior  lip, 
is  drawn  well  down,  and  the  left  index-finger  gently  presses  the  tent  up- 
ward, in  place  of  the  applicator.  By  gently  manipulating  the  point  of  the 
tent,  as  of  a  sound,  it  may  often  be  gniided  past  the  obstruction.  Of  course, 
the  rule  of  not  choosing  too  large  a  tent  ajDplies  here,  as  well  as  to  sponge- 
tents,  and  the  tupelo,  still  to  be  described. 

One  tampon  will  not  suffice  to  fix  the  tent,  unless  it  chances  not  to 
show  any  tendency  to  escape.  It  is  generally  best  to  pack  the  vaginal 
vault  pretty  tightly  with  several  tampons. 

In  order  to  obtain  the  utmost  expansion  of  a  laminaria  tent,  it  should 
be  left  in  utero  at  least  eighteen  hours.  I  generally  leave  them  in  over- 
night, keeping  the  patient  in  bed,  and  usually  also  slightly  under  morj)hine 
until  the  forenoon  of  the  next  day.  Expansion  does  not  commence  as 
rapidly  as  with  sponge-tents,  nor  does  it  reach  its  limit  so  soon.  The 
laminaria  dilates  more  slowly,  but  with  unsparing  persistency,  and  the  pain 
is  generally  more  severe,  especially  in  cases  of  constricted  internal  os.  I 
have  seen  decidedly  more  temporary  reaction  (reflex  naiisea,  vomiting,  and 
shock)  during  laminaria  dilatation,  than  with  sponge-tents.  It  is  therefore 
c^uite  as  imj)ortant  to  observe  every  precaution  against  inflammation,  even 
though  laminaria  does  not  possess  the  pernicious  quality  of  favoring  de- 
composition of  the  fluids  absorbed  b}'  it. 

The  laminaria  is  also  removed  through  the  speculum,  the  end  pro- 
jecting from  the  cervix  being  seized  in  stout  forcej)s,  and  counter-pressure 
against  the  cervix  being  exercised  by  the  finger  or  instrument  already 
described.  By  a  twisting,  half  rotary  movement,  the  tent  is  then  loosened 
from  the  grasp  of  the  uterus,  and  removed.  The  almost  invariable  greater 
expansion  of  its  internal  end,  over  the  middle  portion,  renders  this  act 
quite  difficult,  and  the  dragging  of  the  rough  tent  through  the  (in  spite  of 
the  dilatation)  still  narrow  internal  os,  gives  rise  to  injury  and  hemorrhage 
from  that  point.  This  cannot  be  avoided,  and  the  abrasion  is  always  less 
than  that  from  a  sponge-tent.  After  removal  of  the  tent,  the  uterus  and 
vagina  are  cleansed,  and  the  patient  returned  to  her  bed  under  the  same 


DILATATION    WITHOUT    CUTTING    INSTRUMENTS.  281 

precautions  as  described  after  sponge-tents.  I  am  in  the  habit,  after  the 
removal  of  any  form  of  tent,  of  passing  a  cotton-wrapped  applicator  satu- 
rated with  pure  carbolic  acid  or  carbolic  and  glycerine  into  the  uterine 
cavity,  as  an  additional  precaution  against  infection.  It  veiy  seldom  hap- 
pens that  an  expanded  laminaria  tent  becomes  so  soft  through  long  macei'- 
ation,  as  to  be  torn  in  pieces  during  removal.  With  sponge-tents  this 
is  by  no  means  an  uncommon  occurrence. 

Professor  B.  S.  Schultze,  of  Jena,  Germany,  has  lately  described  a  new 
method  of  dilating  the  uterus  with  laminaria  tents,  which  is  characterized 
chiefly  by  exceeding  care  in  disinfecting  vagina,  tents,  and  uterine  cavity, 
by  carbolic  applications  during  the  whole  process,  and  by  never  allowing 
a  tent  to  come  in  contact  with  a  fresh  wound.  His  method  is  briefly  as 
follows :  The  du-ection  and  calibre  of  the  uterine  canal  is  first  ascertained 
by  careful  probing  with  graduated  probes  of  soft  metal,  bent  as  nearly  as 
possible  to  the  curve  of  the  canal,  as  susjDected  by  bimanual  examination. 
If  a  di'op  of  blood  follows  the  probing,  showing  an  injury  to  the  mucous 
membrane,  the  laminaria  introduction  is  deferred  twenty-four  hours.  The 
cervix  is  exposed  by  a  duckbill  speculum,  applied  in  knee-chest  position, 
the  uterus  drawn  down  by  a  tenaculum,  and  again  probed.  If  blood  fol- 
lows, there  is  another  delay  of  twenty-four  hours  and  then  a  repetition  of 
the  steps  abeady  stated.  The  vagina  is  cleansed  by  cotton  wads  soaked  in 
a  three  per  cent,  solution  of  carbolic  acid,  in  w^hich  all  the  instruments  (i3re- 
viously  steeped  in  boiling  water)  are  kept.  A  laminaria  tent,  corresponding 
in  length  and  size  to  the  uterine  canal,  is  now  dipped  for  a  moment  in  boil- 
ing carbolized  water,  and  then  bent  to  the  proper  curve,  as  ascertained  by 
the  probe,  and  hardened  in  cold  water,  also  carbolized.  With  forceps  the 
tent  is  now  gently  inserted  into  the  uterine  canal,  carefully  following  its 
curve.  If  any  bleeding  occiu'S,  the  operation  is  defeiTed  twenty-four  hours. 
If  the  tent  meets  with  an  obstacle  which  is  not  easily  overcome,  the  probe 
is  used.  When  the  tent  is  in  situ,  a  tampon  of  salicylated  cotton,  soaked 
in  carbolic  solution,  is  placed  over  the  cervix,  then  several  glycerine  tam- 
pons ;  tenaculum  and  speculum  are  removed,  and  the  patient  is  placed 
on  her  side,  and  put  to  bed,  where  she  remains  in  perfect  quiet  for  several 
hours.  Abdominal  pain  is  relieved  by  hot- water  compresses.  In  from  six 
to  eight  hours  the  tent  has  fully  expanded,  but  it  may  be  left  in  utero  for 
twelve  to  sixteen  hours.  It  is  removed  precisely  in  the  same  position  as  it 
was  introduced,  the  tent  being  very  carefully  withdrawn  to  prevent  injury. 
The  canal  is  then  measured  again  with  thicker,  flexible  probes,  and  if 
it  has  reached  a  width  of  7  mm.  above  the  os  internum,  which  is  gen- 
erally the  case  with  an  original  calibre  of  4  to  5  mm.  after  one  dilata- 
tion, the  introduction  of  a  flexible  metal  catheter  of  a  diameter  of  6  mm. 
is  feasible,  through  which  the  uterine  cavity  is  irrigated  with  one-fourth  to 
one-half  pint  of  a  two  to  three  per  cent,  carbolized  solution  of  about  100° 
F.  Any  fluid  medicinal  application  may  now  also  be  made.  The  catheter 
should  also  have  the  curve  of  the  uterine  canal.  The  propelling  power  of 
the  water  is  the  ordinary  fountain  irrigator.  If  further  dilatation  is  de- 
sired, a  second  larger  laminaria  tent  is  inserted  after  the  irrigation,  which  is 


282  MIlSrOR    GYNECOLOGICAL    MANIPULATIONS. 

retained  and  removed  in  the  same  manner,  and  may  be  followed  by  a  third 
and  fouiih  if  necessary,  or  by  two  at  a  time.  In  normally  located  or  ante- 
verted  or  anteflexed  uteri,  the  knee-breast  position  is  the  best  ;  for  retro- 
displacements  the  gluteo-dorsal.  Iii  thirty-six  hours  a  virgin  uterus  can 
be  opened  up  to  the  fundus  for  the  exploring-finger. 

Schultze  reports  having  applied  the  laminaria  in  this  manner  over  a 
thousand  times,  and  that  he  observed  pelvic  cellulitis  in  but  five  cases  after 
this  procedure,  and  the  diagnostic  and  therapeutic  measures  which  were 
required.  In  hyperplasia  and  subinvolution  of  the  uterus,  repeated  forcible 
dilatation  with  a  diverging  steel  dilator  j)roved  very  beneficial  in  promoting 
absorption  and  involution. 

Tupelo  Tents. — The  disadvantages  inherent  to  the  two  agents  for  grad- 
ual dilatation  just  described — of  sponge-tents,  the  danger  ;  of  laminaria, 
the  small  size  and  unequal  expansion — these  disadvantages  led  the  profes- 
sion to  seek  for  a  substance  which,  while  it  would  not  favor  decomposition 
of  fluids,  would  absorb  them  rapidlj'  and  thoroughly,  and  could  be  pro- 
cured in  sizes  sufficient  for  more  thorough  dilatation  than  the  laminaria. 
Such  an  agent  should  possess  the  range  of  size,  the  rapid  and  equable  ex- 
pansion, and  the  softness  of  texture  of  the  sponge-tent,  and  the  compara- 
tive safety  of  the  laminaria.  This  substance  has  been  found  within  the  past 
few  years  in  the  root  of  the  nyssa  aquatica,  or  tupelo-tree  of  the  Southern 
States.  This  root  comes  in  sizes  as  thick  as  a  man's  wrist.  It  is  so  soft 
as  to  be  easily  cut  to  any  shape  or  size  desired  with  the  penknife  ;  it  is 
capable  of  a  great  degree  of  compression  ;  it  absorbs  fluids  rapidly,  and 
expands  to  at  least  double  its  compressed  size  ;  when  exjDanded  its  surface 
is,  although  not  i^erfectly  smooth,  not  sufficiently  rough  to  injure  the  mu- 
cous membrane  diuing  its  removal ;  it  does  not  favor  decomposition  of 
fluids,  indeed,  I  have  never  found  a  tupelo  tent  to  possess  the  slightest 
offensive  odor  after  having  been  left  in  utero  over  twelve  hours.  The  ra- 
pidity of  expansion  of  the  tujDelo  almost  equals  that  of  the  sponge  tent ; 
therefore,  it  can  be  used  when  the  dilatation  and  the  diagnostic  or  thera- 
peutic purpose  for  which  it  was  made  admit  of  as  little  delay  as  possible. 
Tupelo  tents  are  now  made  of  all  sizes,  from  a  knitting-needle  to  a  thumb, 
and  of  any  desired  length.  They  can  be  procured  larger,  but  so  far  no  use 
has  been  found  for  larger  sizes.  The  usual  length  is  like  that  of  laminaria, 
two  inches.  They  are  prepared  by  subjecting  the  root  to  excessive  press- 
ure in  a  machine  under  dry  heat.  The  surface  is  smooth,  although  not 
polished,  and  they  are  therefore  far  less  likely  to  sHp  out  of  the  cervix  than 
the  laminaria.  Besides,  after  having  been  used  once,  they  can  be  cleaned, 
disinfected,  compressed,  and  again  used  as  though  they  were  new.  This 
can  scarcely  be  done  ^^ith  sponge  or  laminaria  tents,  at  least  the  trouble  is 
greater  than  the  gain. 

An  additional  advantage  which  the  tupelo  tent  has  over  the  laminaria, 
besides  its  size,  and  in  which  it  resembles  the  sponge,  is  that  it  softens  the 
tissues  and  renders  them  more  succulent  and  dilatable.  The  dilatation  of 
tupelo,  when  very  thoroughly  compressed,  is  at  least  one  hundred  per 
cent.,  and  usually  very  uniform,  the  ring  of  constriction  indicating  the  in- 


DILATATION    WITHOUT    CUTTING    INSTRUMENTS. 


283 


ternal  os  being  mucli  less  marked  tlian  in  laminaria.  The  sjDonge-tent 
also  shows  this  constriction  in  marked  cases.  The  degree  of  expansion 
of  a  set  of  five  tupelo  tents  is  illustrated  by  the  following  diagram,  the 
dotted  outline  of  each  tent  showing  its  expansion. 

The  large  size  and.  safety  of  the  tupelo  tents  render  them  available 
in  cases  where  the  danger  of  septic  infection  has  led  us  to  dread  sjjonge- 
tents  and  to  substitute  soft  rubber  dilators  with  but  imperfect  success, 
viz.,  constricted  cervical  canal  in  abortion,  and  premature  labor,  cases  in 
which  the  small  size  of  the  laminaria  tents  renders  them  useful.  I  have 
repeatedly  employed  the  large  tupelo  tents  in  abortion  to  hasten  the  ex- 
pulsion of  the  ovum,  or  permit  the  manual  removal  of  the  placenta,  with 


Fig.  131.— Degree  of  Expansion  of  Tupelo  Tents  (P.  F.  M.). 


great  satisfaction.  In  a  couple  of  hours  the  tent  had  dilated  the  cervix 
sufficiently  for  my  purpose.  In  stenosis  of  the  vagina,  where  septic  infec- 
tion is  also  to  be  feared,  the  large  tupelo  tents  exj)and  the  canal  to  the  de- 
sired size,  so  also  in  stricture  of  the  rectum. 

In  fact,  whenever  thorough,  rapid,  and  safe  dilatation  by  gradual 
methods  is  desired,  the  tupelo  tent  is  the  agent  to  be  chosen.  In  only  one 
particular  has  it  as  jet  failed  to  supplant  the  sponge-tent,  viz.  :  in  the  irri- 
tating, stimulating,  and  softening  effect  which  the  latter  has  on  the  sirr- 
rounding  tissues,  a  property  of  great  value  in  subinvolution,  hyperplasia, 
and  atrophy  of  the  uterus. 

The  method  of  introducing  the  tupelo  tent  is  precisely  identical  with  that 


284  MINOR    GYNECOLOGICAL    MANIPULATIONS. 

of  the  laminaria,  except  that  the  tent  being  solid,  it  must  be  seized  with 
the  forceps  instead  of  being  impaled  on  an  applicator.  It  is  dijDped  in 
vaseline  and  introduced,  the  same  precaution  having  been  taken  not  to 
choose  too  large  a  tent.  A  tampon  is  also  best  placed  over  the  cervix. 
Accordingly  as  a  rapid  conclusion  is  desired,  or  a  more  thorough  dilating 
effect  intended,  the  tent  may  be  removed  in  two  or  three  hours,  or  left  in 
for  twelve  to  eighteen  hours.  Longer  than  the  latter  period  would  scarcely 
ever  be  necessary  or  useful,  and  I  have  even  found  one  hotu'  sufficient  to 
produce  a  dilatation  of  requisite  size  to  permit  thorough  curetting  of  the 
uterine  canal.  It  is  wise  to  use  the  same  precautions  after  tupelo  as  after 
other  tents. 

One  of  the  great  advantages  of  the  tupelo  tent  is,  that  if  it  has  been 
found  impossible  to  force  the  tent  chosen  for  the  casethi'ough  the  cervical 
canal,  it  need  not  be  thrown  away  like  the  s]Donge-tent  (which  has  become 
ex^Danded  and  rough)  or  laid  aside  for  another  smaller  size,  like  the  lami- 
naria (which  smaller  size  may  not  be  at  hand,  and  cannot  be  at  once  pre- 
pared, as  the  laminaria  is  too  hard  for  whittling) — but  can  be  whittled 
down  in  a  moment  -with  a  penknife  to  the  requu-ed  size. 


Fig.  132.— Tupelo  Tent  No.  3,  after  Eighteen  Hours'  Dilatation  in  TJtoro,  showing  Slight  Constriction 
Produced  by  Internal  Os  (P.  P.  M.J. 

Another  advantage  is  that  the  tupelo  can  be  introduced  immediately 
after  a  fresh  incision  has  been  made  (as  after  dividing  the  internal  os),  be- 
cause it  does  not  favor  septic  absorption.  And  as  many  tupelo  tents  can 
be  inserted,  one  after  the  other,  as  may  be  desii'ed,  for  the  same  reason. 
This  property,  to  be  sure,  belongs  to  the  laminaria  also. 

Tents  and  bougies  made  from  the  bark  of  the  slippery-elm  tree  have 
been  used  by  some  gynecologists.  Dr.  Byford,  of  Chicago,  highly  recom- 
mends these  tents  for  their  mildly  dilating  and  safe  qualities  in  flexions 
of  the  uterus,  and  bougies  of  the  root  in  different  sizes  have  been  intro- 
duced to  the  profession  by  Dr.  Skene,  of  Brooklyn,  for  use  in  constric- 
tion and  tortuosity  of  the  uterine  canal.  The  glutinous  proj)erty  of  the 
slippery-elm  renders  these  tents  almost  innocuous,  while  their  repeated  in- 
troduction gradually  relaxes  the  uterine  fibre,  and  produces  moderate  dila- 
tation. 

Tents  made  of  the  compjressed  pith  of  the  corn-stalk  have  been  recom- 
mended by  Dr.  Goldsmith,  of  Georgia,  and,  I  am  told  by  gentlemen  who 
have  had  occasion  to  use  them,  form  an  efficient  substitute  for  the  more 
powerfully  dilating  tents,  when  the  latter  do  not  happen  to  be  at  hand. 
The  same  may  be  said  of  the  tents  of  compressed  elder  pith. 

The  use  of  tents  made  from  the  root  of  the  gentian  plant  (I  believe  first 
introduced  by  Winckel,  of  Dresden)  has  not  become  popular.     If  it  is  de- 


DILATATION"    WITHOUT    CUTTING    IISrSTEUMEXTS.  285 

sired  to  imiDregnate  the  tent  with  some  medicinal  agent,  according-  to 
Clirobak,  the  slow  and  mild  dilating  property  of  the  gentian  renders  these 
tents  especially  available. 

Indications  for  Dilatation  of  the  Uterus. 

The  indications  for  dilating  the  uterine  canal  by  one  or  more  of  the 
foregoing  methods  consist  either  in  conditions  which  interfere  with  the 
exit  of  fluids  or  solid  bodies  from,  or'  the  entrance  of  fluids  or  instruments 
into  the  uterine  cavity  ;  or  in  aflections  which  require  the  dilatation  as  a 
therapeutic  measure  in  itself. 

1.  Conditions  of  the  first  variety — Interference  icith  the  exit  of  fluids  or 
solid  bodies  from  the  uterine  cavity — are  :  Constriction  of  the  uterine  canal 
(stenosis,  flexion,  rigidity).  The  fluids  Avhich  are  thus  prevented  from  es- 
caping are  comprised  in  one,  the  menstrual  blood.  The  solids  which  may 
be  retained  are  fibroid  tumors,  the  immature  or  full-grown  fetus,  the  pla- 
centa. 

2.  Conditions  of  the  second  variety — Interference  ivith  the  entrance  of 
iiuids  or  instruments  into  the  uterine  cavity — are  also  :  Constriction  of  the 
uterine  canal,  from  the  same  causes.  The  fluid  which  is  ]3revented  from 
entering  is  the  seminal  fluid  ;  the  instruments,  are  the  sound,  applicators, 
curette,  forceps,  syringe,  endoscope,  the  finger. 

The  diseases,  therefore,  in  which  dilatation  may  be  required,  are  : 
organic  constriction  of  the  uterine  canal,  flexion  (chiefly  anteflexion), 
dysmenorrhea,  sterility,  all  conditions  of  the  endometrium  which  require 
the  free  application  of  medicinal  agents  to  that  j)art  (endotrachelitis,  hem- 
orrhage, endometritis,  vegetations,  malignant  disease,  hyjDerplasia,  subin- 
volution). 

3.  The  conditions  in  which  dilatation  is  required  as  a  therapeutic  meas- 
ure in  itself  are  areolar  hyperplasia  and  subinvolution  ;  again,  atrophy  of 
the  uterus  ;  neuralgic  or  sjDasmodic  dysmenorrhea,  not  dependent  on  or- 
ganic constriction  ;  endotrachelitis,  with  cystic  hyperjDlasia. 

Special  Indications  for  each  llethod  of  Dilatation. — To  a  certain  extent 
the  purposes  for  which  each  of  the  foregoing  methods  of  dilatation  is  spe- 
cially indicated  have  been  pointed  out  in  the  description  of  the  method. 
As  a  general  rule,  where  repeated  o^ajnd  dilatation  of  an  entirely  undilaled 
uterine  canal  is  desired,  the  graduated  sounds  and  steel  divergent  dilators 
are  preferable. 

Where  rapid,  dilatation  of  an  ah^eady  somewhat  dilated  canal  is  in- 
tended, the  inflatable  rubber  tubes  of  Molesworth  are  the  best  instru- 
ments. The  dilatation  in  such  cases  probably  does  not  need  frequent 
repetition. 

In  gradual  dUatation  of  an  undilated  canal,  tupelo,  laminaria,  sponge. 
Frequent  repetition  is  also  unusual. 

In  gradual  dilatation  of  a  somewhat  dilated  canal,  tupelo  (larger  sizes), 
sponge,  Emmet's  water  dilator.  Also  not  likely  to  be  frequently  repeated 
in  the  same  case. 


286  MINOR    GYNECOLOGICAL    MANIPULATIONS. 

Further,  where  moderate  dilatation  is  desired,  sounds,  divergent  dila- 
tors, small  tupelo,  laminaria,  and  sponge- teats. 

For  thorough  dilatation,  large  tupelo  and  sponge-tents,  Molesworth's 
and  Emmet's  water  dilators. 

Rapid  repealed  dilatation  of  an  entirely  undilated  uterine  canal  is  gen- 
erally indicated  in  dysmenorrhea  and  sterility.  Either  the  gTaduated  sounds 
or  the  divergent  dilators  may  be  used,  in  the  manner  fully  described  under 
each  head.  I  most  decidedly  prefer  the  divergent  dilators,  and  have  seen 
excellent  results  from  their  frequent  and  careful  employment. 

In  dysmenorrhea  from  constriction  of  the  canal  or  flexion,  a  few  sit- 
tings, say  two  a  week  for  a  couple  of  months,  one  dilatation  being  prac- 
tised immediately  before  the  expected  period,  will  generally  result  in 
decided  improvement  or  cure.  Whether  this  is  due  to  the  removal  of  a 
mechanical  obstruction  (Emmet  does  not  beheve  in  "obstructive  dj's- 
menoiThea ")  or  to  the  distention  of  spasmodically  contracted  muscular 
fibres  at  the  internal  os  (practically  a  mechanical  obstacle),  a  spasmodic 
stricture — I  will  not  attempt  to  decide.  That  the  dilatation  does  good  in 
these  cases  I  have  frequently  seen.  They  are  usually  cases  of  young  un- 
married women,  or  of  nulliparae,  in  whom  more  or  less  anteflexion  is  found 
to  be  the  only  pathological  feature  about  the  uterus,  which  readily  admits 
the  sound.  The  straightening  of  the  canal  by  the  sound  sometimes  relieves 
the  menstrual  pain,  but  this  result  is  much  more  certain  after  thorough 
dilatation.  I  have  even  seen  one  dilatation  relieve  a  dysmenorrhea  of 
eleven  years'  standing  in  a  case  of  sterility  depending  on  a  shai-p  anteflexion. 
The  treatment  may  need  to  be  repeated  once  or  twice  during  several  in- 
termenstrual periods,  before  achieving  permanent  relief. 

In  sterihty,  the  treatment  requires  to  be  much  more  persistent  and 
thorough  than  in  dysmenorrhea.  My  practice  in  those  cases  in  which  the 
sterility,  evidently,  or  so  far  as  examination  shows,  depends  on  torsion  or 
constriction  of  the  uterine  canal,  or  on  a  conical  cervix,  or  on  an  excessive 
rugosity  of  the  endotrachelian  mucous  membrane,  has  been,  flrst,  to  dilate 
the  canal  thoroughly,  perhaps  even  incise  the  external  os,  as  described 
under  Applications  to  the  Cervix  ;  and  then  to  maintain  the  patency  of 
the  canal  by  the  weekly  passage  of  a  medium-sized  dilator  for  a  couple  of 
months.  As  soon  as  the  canal  appears  permanently  open,  I  tell  the  pa- 
tient to  report  after  every  menstrual  period,  or  its  date  if  it  fails  to  appear. 
In  the  latter  case,  the  chance  is  that  the  treatment  has  proved  successful. 
If,  however,  impregnation  has  not  yet  taken  place,  as  shown  by  the  return 
of  menstruation,  I  proceed  to  dilate  the  canal  again  moderately,  teU  the 
patient  to  use  a  cleansing  borax  or  phosphate  of  soda  injection  every  even- 
ing (to  neutralize  any  excessive  acidity  of  the  vaginal  secretion,  which  is 
injurious  to  the  spermatozoa),  and  to  practise  coition  that  night  and  every 
night  for  a  week  subsequently.  By  repeating  this  process  month  after 
month,  a  successful  result  was  ultimately  obtained  in  a  certain  proportion 
of  cases,  although  I  must  confess  that  the  number  of  cases  in  which  impreg- 
nation finally  took  place  was  but  small  in  proportion  to  the  whole  number 
of  cases  of  sterihty.     Still,  this  may  have  been  partly  due  to  the  want  of 


DILATATION    WITHOUT    CUTTING   INSTRUMENTS.  287 

perseverance  of  many  of  the  patients,  and  to  causes  not  removable  by  dila- 
tation. In  one  case  the  patient,  who  had  been  manied  eight  years  with- 
out becoming  pregnant,  the  sterility  doubtless  being  due  to  a  long  conical 
cervix  and  narrow  external  os,  did  not  conceive  until  five  months  after  the 
treatment  by  dilatation  (laminaria  twice  and  subsequent  divergent  dilators 
several  times)  had  been  entirely  suspended.  Dr.  Godson,  of  London,  has 
recently  (London  Obst.  Soc.)  reported  five  cases  of  dysmenoiThea  and 
steriUty  of  several  years  standing,  in  which  repeated  dilatation  by  gra- 
duated metalhc  bougies  not  only  cured  the  menstrual  pain,  but  was  also 
speedily  followed  by  conception.  In  the  discussion,  a  number  of  gentle- 
men reported  frequent  cures  of  dysmenorrhea  and  sterihty  by  similar  rapid 
dilatation  of  the  uterus.  Dr.  Gi^aily  Hewitt  using  a  divergent  steel  two- 
branched  dilator,  Drs.  Carter,  Galabin,  and  others,  graduated  bougies. 
Dr.  Godson's  jDractice  was  to  obtain  the  greatest  possible  dilatation  at  each 
sitting  by  gradual  insertion  of  larger  bougies. 

This  rapid  dilatation  may  also  be  practised  when  an  application  is  to 
be  made  to  the  endometrium.  The  divergent  dilator  is  the  best  instru- 
ment for  this  purpose  also. 

Drs.  Ball,  of  Brooklyn,  Goodell  and  Ellwood  Wilson,  of  Philadelphia, 
Hanks  and  Watts,  of  New  York,  have  reported  exceedingly  satisfactory 
results  in  dysmenorrhea  and  sterility  depending  on  constriction  of  the 
uterine  canal  and  flexions,  chiefly  those  of  a  congenital  character,  by  for- 
cibly dilating  the  uterus  under  ether  with  sounds  or  divergent  dilators  to 
the  utmost  limit,  keei^ing  up  the  dilatation  for  fifteen  to  thirty  minutes  or 
longer,  and  repeating  it,  if  necessary,  every  month  or  oftener.  The  pa- 
tient, of  course,  is  kept  in  bed  and  treated  as  she  would  be  after  any 
operation  on  the  genital  organs,  which  indeed  this  maneuvre  is.  Dr.  Ball 
even  introduces  a  large  hard-rubber  plug  into  the  dilated  uterus  immedi- 
ately after  removing  the  dilator,,  and  has  this  plug  woi'n  for  a  week  or 
more,  during  which  time  the  patient  is  kept  in  bed.  All  these  gentlemen 
unite  in  praising  the  slight  reaction  following  this  treatment.  Still,  one 
case  of  death  from  peritonitis  due  to  it  is  reported  by  Dr.  Watts.  It  cer- 
tainly looks  and  sounds  very  plausible,  although  some  i^rominent  gynecol- 
ogists pronounce  this  forcible  hyper-dilatation  of  the  uterus  a  barbarous 
practice.  It  seems  to  me  particularly  applicable  and  justifiable  in  slen- 
der, anteflexed  uteri  with  long,  conical  cervix,  when  no  counter-indica- 
tion exists  and  the  patient  is  unwilling  or  financially  unable  to  submit 
to  the  systematic  protracted  course  of  gradual  dilatation  described  by 
Schultze,  or  the  frequent  moderate  rapid  dilatation  with  divergent  instru- 
ments. The  latter  method  certainly  is  too  mild  and  incomplete  in  very 
many  of  the  cases  in  which  the  pecuHar  shape  and  direction  of  the  uterine 
canal  and  the  dense  character  of  the  uterine  tissue  requires  thorough  dila- 
tation. 

Rapid  dilatation  of  an  already  somewhat  dilated  canal  may  be  called 
for  when  a  fibroid  polypus  or  a  placenta  after  abortion  is  to  be  rapidly 
removed  becaiise  the  decomposition  of  the  foreign  body  has  begun.  Or, 
violent  uterine  hemorrhage  may  require  the  immediate  thorough  dilata- 


288  MINOR    GYNECOLOGICAL    MANIPULATIONS. 

tion  of  the  canal  for  the  removal  of  tlie  cause  (placenta  or  vegetations  by 
curette)  and  the  application  of  styptics  or  the  uterine  tampon,  or  a 
sloughing  uterine  tumor  (fibroid  or  malignant)  calls  for  thorough  disin- 
fectant ii'rigation  of  the  cavity.  These  indications  are  fulfilled  exceed- 
ingly well  by  the  tubes  of  Molesworth's  instrument,  size  after  size  of  which 
may  be  used  at  one  sitting  until  the  expansion  is  sufficient.  The  dilata- 
tion is  greatly  facilitated  by  the  softness  and  serous  imbibition  of  the  tis- 
sues generally  to  be  found  in  such  cases. 

Gradual  dilatation  of  an  undilated  canal  is  practised  in  the  same  con- 
ditions as  rapid  dilatation,  but  the  difference  is  that  the  effect  obtained 
from  the  gradual  method  is  more  permanent  and  thorough  than  from  the 
rapid.  In  dysmenoiThea,  and  chiefly  in  sterility,  if  the  repeated  rapid 
method  fails,  the  canal  may  be  thoroughly  dilated  by  tupelo,  laminaria,  or 
sponge  tents,  either  once,  or  at  intervals  of  one  or  more  months,  in  order 
to  insure  a  permanent  effect.  In  the  intervals  the  canal  may  be  kept  per- 
vious by  mild  rapid  dilatation.  Gradual  dilatation  may  further  be  prac- 
tised as  a  preparatory  step  to  intra-uterine  medication,  to  the  introduction 
of  a  stem  pessary,  or  the  removal  of  intra-uterine  growths. 

Gradual  dilatation  of  a  soijiewhat  dilated  canal  may  be  indicated  in  the 
same  cases  where  rapid  dilatation  by  Molesworth's  instrument  has  been 
recommended,  when  there  is  no  haste,  and  a  gi-adual  expansion  seems 
safer.  Thus  we  may  use  the  large  tupelo-tents  in  rigidity  of  the  external 
OS  and  cervical  canal  in  abortion  or  labor,  in  constricted  vagina,  in  strict- 
ure of  the  rectum.  The  sponge-tent,  which  would  dilate  quite  as  well,  is 
decidedly  counter-indicated  in  cases  of  labor  or  abortion,  where  its  septic 
properties  are  rendered  specially  dangerous  through  the  great  vascularity 
of  the  parts  during  pregnancy. 

In  a  uterus  partly  dilated  by  a  polyjous  which  is  gradually  forcing  its 
way  down,  or  by  the  softening  process  accompanying  long-continued 
bloody,  serous,  or  j)urulent  discharge,  the  larger  varieties  of  tents  are  also 
useful  to  complete  the  dilatation. 

All  dilating  agents  which  act  by  absorption  of  fluids  (all  the  tents, 
therefore),  and  the  dilatable  rubber  tubes,  can  be  used  as  uterine  tampons 
when  a  sudden  arrest  of  hemorrhage  is  desired.  They  may  be  left  in  the 
uterus  for  various  periods,  from  one  hour  to  twenty-four  hours,  accord- 
ing to  rules  already  given  and  the  necessity  of  the  case. 

Sponge-tents  possess  special  indications,  through  their  peculiar  property 
of  causing  serous  imbibition  and  relaxation  of  the  surroundiug  tissues, 
and  the  stimulant,  alterative  effect  which  their  presence  exerts  on  torpid 
and  enlarged  uteri.  They  are  therefore  most  beneficial  in  hyperplasia, 
subinvolution,  and  atrojohy  of  the  uterus.  Another  special  effect  of  sponge- 
tents  is  the  cure  of  endotrachelitis  by  the  (really  involuntary)  removal  of 
the  hyperplastic  glands  when  the  sponge  is  withdrawn.  The  fine  meshes 
of  the  s^Donge  become  interlaced  with  the  follicles,  which  are  forcibly  torn 
away  when  it  is  removed.  The  effect  of  local  applications  is,  of  course, 
greatly  enhanced  by  this  abrasion  of  the  cervical  mucosa. 

A  peculiar  use  for  sponge-tents  has  been  described  by  Spiegelberg, 


DILATATION"    WITHOUT    CUTTING   INSTRUMENTS.  289 

viz.,  to  diagnose  between  beginning  scirrlious  cancer  of  the  cervix  and  areo- 
lar hyperplasia  of  that  part.  Both  affections  are  characterized  by  great 
density  and  hardness  of  tissue,  and  in  order  to  tell  which  is  the  cancer, 
Spiegelberg  recommends  introducing  a  sponge-tent ;  if  the  tent  fails  to 
soften  the  cervix  and  to  dilate  the  canal  in  the  usual  manner,  he  says  the 
case  is  one  of  scirrhus.  I  have  no  experience  with  this  test,  but  should 
certainly  recommend  it  in  view  of  the  difficulty  of  diagnosing  cancer  of 
the  cervix  in  its  early  stage. 

A  similar  stimulant  and  alterative  effect  in  chronic  uterine  enlargements, 
and  also  in  old  indurated  pelvic  peritonitis  and  cellulitis,  is  claimed  by 
Schultze  for  the  laminaria  employed  after  his  peculiar  method.  Only  when 
precautions  such  as  those  recommended  by  him  are  scrupulously  observed 
would  the  dilatation  of  the  uterus  by  any  means  be  justifiable  in  chi'onic 
inflammatory  conditions  of  the  parametrium. 

The  special  advantages  of  each  of  these  dilating  agents  have  been  dis- 
cussed during  the  description.  I  will  merely  add  a  brief  synojDsis  of  the 
conditions  in  which  each  article  is  preferable  or  pre-eminently  useful : 

Oraduated  Sounds  and  Steel  Diverging  Dilators. — In  dysmenorrhea  and  sterility  de- 
pending on  a  constricted,  flexed,  rugous,  uterine  canal,  where  only  moderate, 
temporary  dilatation  is  desired,  or  where  the  dilatation  is  to  be  frequently  re- 
peated. For  intra-uterine  applications.  In  all  cases  where  previous  preparation 
is  not  desired. 

Dilatable  Rubher  Tubes. — In  already  moderately  dilated  uterine  canals,  with  soft 
dilatable  walls  (uterine  discharges,  fibroid  tumors,  abortion,  rigid  os  during  labor). 

Sponge-tents. — Where  stimulation,  changes  of  nutrition,  serous  discharges,  abrasion  of 
the  endotrachelium  are  desired  (areolar  hyperplasia,  subinvolution,  atrophy  of  the 
uterus,  endotrachelitis).  For  differential  diagnosis  between  cancer  and  hyperplasia 
of  cervix. 

Laminaria,. — Where  the  canal  is  very  narrow  or  tortuous,  or  its  walls  very  rigid  (flex- 
ions, sterility,  dysmenorrhea),  as  an  aid  to  rapid  dilatation  by  sounds,  etc.,  only 
for  occasional  use. 

Tupelo. — Also  where  the  canal  is  narrow,  or  tortuous  ;  further,  where  thorough,  re- 
peated or,  rapid  dilatation  is  desired  ;  after  incision  of  cervical  canal.  Wliere 
thorough  dilatation  is  intended,  and  septic  infection  is  specially  to  be  guarded 
against.  Therefore,  as  a  substitute  for  sponge-tents.  In  fact,  whenever  easy, 
thorough,  and  safe  dilatation  is  desired.     The  best  absorbent  dilator. 

»  Counter-indications  and  Dangers. 

So  much  has  already  been  said  on  this  subject  in  the  body  of  this  sec- 
tion that  it  will  be  necessary  to  add  but  a  few  words  here. 

The  usual  counter-indications  to  all  operative  interference  with  the 
uterus,  or  to  the  passage  of  any  instrument  into  the  uterine  cavity — pres- 
ent or  recent  inflammation  of  the  utei-us  or  adnexa— api)ly  even  more  to 
uterine  dilatation  than  to  any  procedure  previously  discussed.  Most  to  be 
avoided  and  guarded  is  the  sponge-tent ;  least,  the  tupelo. 

The  dangers  are  precisely  the  Hghting  up  of  those  inflammatory  affec- 
tions w-hich  counter-indicate  dilatation ;  besides,  septic  infection  from 
sponge-tents.  I  have  ah'eady  spoken  of  the  frequent  deaths  and  accidents 
19 


290  MINOR    GYNECOLOGICAL   MANIPULATIONS. 

from  sponges.  Those  from  laminaria  are  much  less  frequent ;  still,  cellu- 
litis occurs  far  too  frequently  to  be  overlooked.  I  have  been  so  fortunate 
as  never  to  have  had  a  vs^oi'se  accident,  after  any  form  of  dilatation,  than  a 
subacute  ovaritis,  but  this  I  have  repeatedly  seen  from  laminaria  and  dila- 
tation with  Elhnger's  instrument.  From  sponge-tents,  Molesworth,  and 
tupelo  I  have  had  no  bad  results.  My  good  fortune  in  this  respect  has 
been  nothing  but  luck,  for  in  spite  of  all  precautions  serious  accidents  have 
happened  to  the  most  experienced  ojoerators.  The  extreme  caution  to  be 
always  observed  with  all  these  manijDulations  has  already  been  sufficiently 
dwelt  upon. 

Although  the  tupelo  is  acknowledged  to  be  the  safest  and  most  reliable 
tent,  even  it  may  produce  pelvic  peritonitis,  two  cases  of  which  were  re- 
cently reported  by  Dr.  C.  C.  Lee,  of  New  York.  Not  the  material,  but 
the  act  of  dilatation  may  therefore  be  the  cause  of  the  inflammatory  re- 
action. 


Dilatation  with  Cutting  Insteuments  (Bloody  Dilatation). 

The  operation  consists  in  dividing  the  cervix  longitudinally  either  on 
one  side  or  both,  through  the  anterior  or  through  the  posterior  lip  ;  or 
quadrilaterally,  crucially.  The  whole  cervix  may  be  divided  from  orifice 
to  orifice,  or  only  the  external  or  the  internal  os.  The  incisions  may  be 
deej),  extending  almost  to  the  vaginal  mucous  membrane  or  the  perito- 
neum (the  bilateral  division  of  Simpson,  and  the  antero-posterior  section 
of  Sims),  or  they  may  be  superficial,  extending  only  through  the  cervical 
mucous  membrane  (the  superficial  trachelotomy  of  Peaslee). 

The  instruments  employed  in  incising  the  cervix  are  either  scissors, 
knives,  or  two-bladed  instruments  separated  by  a  mechanism  in  the  handle. 

Tor  division  of  the  external  os,  simple  long,  straight  scissors  answer 
very  well ;  or  a  long-handled  straight  or  curved  bistoury  may  be  passed 
into  the  cervix  and  cut  out  to  any  desired  depth. 

For  incision  of  the  remainder  of  the  cervical  canal,  and  chiefly  the  in- 
ternal OS,  a  long,  straight,  slender  probe-pointed  bistouiy  is  suificient  in 
many  cases  ;  or  a  movable  knife,  which  can  be  fixed  in  a  handle  at  any  re- 
quired angle,  may  be  preferable  when  a  flexion  is  present.  The  disadvan- 
tage of  these  one-edged  knives  is  that  they  need  to  be  turned  before  the 
incision  ui  the  opposite  wall  can  be  made,  and  that  the  depth  of  the  in- 
cision depends  entirely  upon  the  accuracy  and  steadiness  of  the  operating 
hand.  To  avoid  this  uncertainty,  a  number  of  complicated  instruments 
with  two  blades,  cutting  in  both  directions  at  once,  have  been  devised,  all 
modelled  after  the  original  instrument  of  Simpson.  They  are  called  hys- 
terotomes,  or  metrotomes,  and  are  all  introduced  closed,  ojDened  when  the 
point  has  passed  the  internal  os  and  withdrawn  open,  the  knives  having 
been  set  by  the  screw  at  the  handle,  so  as  to  open  only  a  certain  distance. 
This  distance  depends  upon  the  amount  of  division  desired,  and  upon  the 
thickness  of  the  uterine  wall.     A  correct  estimate  of  the  depth  of  the  in- 


DILATATION    WITH    CUTTING    INSTRUMENTS. 


291 


cislon,  so  as  to  achieve  tlie  result  wished  for,  and  not  to  perforate  the  uter- 
ine envelope,  constitutes  the  difficult  point  in  the  operation. 

An  objection  to  these  mechanically  acting  knives  is  that  the  elasticity 
of  the  uterine  tissue  is  very  liable  to  deceive  the  operator  into  the  beUef 
that  he  has  really  cut  to  the  depth  indicated  by  the  expansion  of  the 
blades,  whereas  the  incision  was  but  a  supei-ficial  one.  On  the  other  hand, 
a  knowledge  of  this  possibility  may  lead  the  operator  to  separate  the 
blades  too  widely,  and  then  by  chance  too  deep  an  incision 
may  be  made.  In  spite  of  the  convenience  of  these  hyste- 
rotomes,  the  most  useful  of  which  are  those  of  Greenhalgh 
and  Stohlmann,  the  objections  named,  their  expense,  and 
the  difficulty  in  keeping  them  clean,  have  led  many  gyne- 
cologists to  return  to  the  knife  with  movable  blades.  I  have 
often  used  a  long  blunt-pointed  bistoury,  turning  the  blade 
to  the  other  side  to  complete  the  division,  and  usually  cut- 
ting quadrilaterally,  until  the  knife-blade  could  be  easily 
passed  through  the  internal  os.  The  probe-pointed  adjust- 
able knife  of  Studley  has  also  proved  useful  in  my  hands. 
Peaslee's  metrotome  is  designed  to  divide  only  the  mucous 
membrane  of  the  cervical  canal,  the  depth  of  the  incision 
not  exceeding  one-fourth  of  an  inch. 

The  indications  for  discission  of  the  uterine  canal  (from 
disciiido,  to  cut  apart,  to  sever)  are  :  1,  to  open  the  canal  in- 
stantaneously for  the  introduction  of  instruments  or  the  re- 
moval of  tumors  ;  2,  constriction  and  tortuosity'  of  the  canal, 
and  the  intention  to  achieve  a  more  permanent  patency  of 
the  passage  than  ordinarily  results  from  bloodless  dilatation. 

Of  the  first  indication  little  more  need  be  said  than  that 
it  is  confined  almost  entirely  to  operations  in  which  the  in- 
ternal OS  is  already  more  or  less  dilated  by  pressure  from 
above  (fibroids  seeking  to  escape)  and  only  the  lower  por- 
tion of  the  cervix  and  external  os  require  division  to  allow 
the  foreign  body  to  be  extruded.  When  the  cervical  canal 
is  split  open,  the  ecraseur,  knife,  scissors,  serrated  spoon,  or  vulsellum  can 
readily  be  introduced  and  the  tumor  removed.  For  the  mere  application 
of  a  medicinal  agent  no  rational  operator  would  think  of  mutilating  the 
ceiwix  by  deep  division. 

The  second  class  of  indications  brings  us  again  to  the  familiar  subject 
of  dysmenorrhea  and  sterility,  which  I  have  handled  so  fully  in  the  sec- 
tion on  Bloodless  Dilatation.  In  many  cases  the  latter  fails,  for  the  uterine 
canal  has  a  persistent  and  perverse  tendency  to  contract  again,  unless  con- 
stantly watched,  no  matter  how  thorough  the  dilatation  may  have  been. 
Therefore,  where  it  is  desired  to  have  a  thorough,  rapid,  and  permanent 
effect,  the  cervix  may  be  divided  through  its  whole  length  by  one  of  the 
knives  above  represented.  If  the  divided  canal  is  kept  properly  patent, 
the  result  of  this  discission  will  certainl}'  be  much  more  gratifying  than 
that  of  mere  dilatation.     But  not  only  is  frequent  dilatation  necessary  for 


Fig.  133.— Stud- 
ley's  Probe-point- 
ed A  d  j  u  s  t  a  ble 
Knife  for  Divi';ion 
o£  the  Internal  Os. 


292 


MIXOR    GYXECOLOGICAL    MAl^IPULATION-S. 


a  considerable  period,  but  also  is  the  operation  liable  to  be  followed  by 
serious  consequences  in  theTvaj  of  inflammation  or  liemon-liage.  It  should 
not,  therefore,  be  hghtly  undertaken,  and  as  regards  dysmenorrhea,  I  cer- 
tainly am  of  opinion  that  only  such  cases  should  be  treated  by  discission 
in  which  a  portion  or  the  whole  of  the  uterine  canal  is  so  contracted  as  to 
render  projjer  gradual  dilatation  impracticable  (as  in  extreme  degrees  of 
conoid  cervix  or  cicatricial  contraction  of  external  or  inter- 
nal os)  or  in  which  rep)eated  dilatation  with  divergent  di- 
lators, tupelo  or  laminaria  tents  has  proved  unavailing. 

As  regards  sterility,  however,  it  is  unquestionable  that 
a  fully  peiwious  or  patent  uteiine  canal  is  more  favorable 
for  conception  than  a  narrow,  toi-tuous  passage.  This  is 
proved  by  the  readiness  with  which  women  in  whom  the 
way  has  once  been  opened  by  the  birth  of  a  child,  con- 
ceive again.  In  view,  thei'efore,  of  the  great  tendency  of 
the  uterine  canal  to  contract  again  after  bloodless  dilata- 
tion and  the  merely  temporary  effects  of  that  method,  the 
discission  of  the  canal  is  certainly  indicated  and  justified 
in  cases  of  stei'ility  in  which  no  other  cause  but  the  nar- 
rowness or  toriuosity  of  the  canal  can  be  detected,  and  in 
which  repeated  bloodless  dilatation  has  failed.  Cases  of 
rigid,  almost  cartilaginous  cervix,  and  conical  pointed  cer- 
vices with  small  "pjinhole  "  external  os,  are,  in  my  opinion, 
those  most  requiring  and  benefited  by  discission. 

Besides  actual  constriction  of  the  cervical  canal  due 
to  congenital  or  acquired  stenosis,  a  relative  constriction 
is  produced  by  flexion  of  the  uterus,  either  at  the  internal 
os  or  of  the  cerrix.  Thus  the  body  of  the  uterus  may  be 
flexed  forward,  or  the  ceiwix  upward.  Either  of  these  de- 
formities (see  Figs.  17  and  18)  is  a  frequent  cause  of  ste- 
rihty,  particularly  the  latter,  and  in  either  the  canal  needs 
to  be  dilated  and  straightened  in  order  to  give  the  sper- 
matozoa free  access  to  the  uterine  cavity.  The  bloodless 
methods  very  generally  fail  in  these  two  malformations ; 
chiefly,  in  anteflexed  cervix  a  division  of  the  posterior  lip  of 
the  cervix  and  formation  of  a  larger  and  straighter  cervical 
canal  is  called  for. 

The  division  of  the  external  os  only  is  indicated  in  con- 
striction of  that  oiifice  for  sterility  and  the  retention  of 
the  normal  or  pathological  discharge  in  the  cervical  cavity. 
In  retroflexion  it  is  very  rarely  indicated  to  divide  either  the  external 
or  the  internal  os,  because,  as  a  rule,  this  displacement  occui'S  in  parous 
women  whose  cervical  canals  have  generally  been  rendered  sufficiently 
patulous  by  previous  partuiition.  Besides,  we  have  in  the  api^ropriate 
vaginal  pessary  a  contrivance  which  hfts  up  the  displaced  fundus  uteri  and 
straightens  the  canaL  The  necessity  for  discission  in  anteversion  or  ret- 
roversion does  not  appear  to  me  (unless  the  canal  be  actually  constricted) 


Fig.  134. — Green- 
halgh's  iletrotome. 


VAEIETIE3    OF    DIVISION    OF    THE    CERVIX. 


293 


because  the  displacement  of  the  cervix  backward  or  forward  and  the  con- 
sequent inaccessibihty  of  the  external  os  to  the  spermatozoa  is  easily  recti- 
fied by  replacing  the  utei'us  and  retaining  it  by  one  of  the  numerous  and 
efficient  intravaginal  supporters.  The  hypertrophy  of  the  uterine  mucous 
lining  by  the  chi-onic  congestion,  so  commonly  present  in  these  versions,  is, 
much  more  rationally  cured  by  dilatation  with  one  of  the  swelling  dilators 
(sponge-tent,  laminaria,  tupelo),  or  by  the  curette,  or  intra-uterine  medi- 
cation, than  by  division  with  the  knife. 

In  latero-versions  and  -flexions,  the  lip  of  the  cervix  corresponding  to 
the  fundus  may  be  divided  in  order  to  form  a  straight  canal,  sterility 
being  the  chief  (often  only)  symjDtom  of  these 
displacements.  If  they  are  congenital,  as  is 
often  the  case,  the  operation  is  indicated  ;  if 
acquired,  i.e.,  the  result  of  parametritic  con- 
traction of  the  respective  broad  ligament,  it 
would  be  unwise  to  incise,  and  a  proper  pes- 
sary would  be  the  only  (and  slight)  resource 
left. 

If  the  anterior  lip  of  the  cervix  projects  be- 
yond the  posterior  with  the  uterus  in  its  nor- 
mal position  of  slight  anteversion,  or  in  real 
anteversion,  this  anterior  lip  may  be  divided 
by  one  clip  of  the  scissors  so  as  to  make  a 
gaping  orifice,  and  remove  the  obstacle  which 
otherwise  this  overlapping  lip  would  consti- 
tute to  the  entrance  of  the  spermatozoa.  Or  the  projecting  anterior  lip 
may  be  amputated  by  the  scissors  (a  slight  operation)  as  shown  in  Fig.  135. 
If  the  lips  of  the  external  os  have  a  peculiar  valvular  shape,  as  shown  in  Fig. 
153,  the  obstructing  flap  or  valve  may  be  excised,  as  shown  by  the  dotted 
lines  in  the  cut.  A  straight,  slender  bistoury  is  passed  about  one-fourth  to 
one-half  inch  into  the  cervical  canal,  and  a  wedge  cut  out,  as  indicated. 

Another  indication  for  the  division  of  the  cervical  canal  is  the  hemor- 
rhage caused  by  sessile  uterine  fibroids.  Baker  Brown  first  practised 
this  method,  and  its  action  has  been  ascribed  by  him  to  the  diAdsion  of  the 
circular  fibres  at  the  internal  os  and  the  consequent  contraction  of  the 
uterine  fibres  about  the  tumor,  and  by  Spiegelberg  to  the  reHef  of  tension 
of  the  uterine  mucosa  and  the  shrivelling  of  its  blood-vessels.  The  method 
is  now  but  little  used,  having  been  supplanted  by  the  (both  for  hemostatic 
purposes  and  ultimate  recovery)  more  efficient  division  of  the  capsule  of 
the  tumor. 


Fig.  125. — Elongation  of  Anterior 
Lip  of  Cervix  (P.  F.  M.J. 


Vakieties   of   Division    of   the  Ceii\t:x  ;    theik    Techxique   and   Special 

Indications. 

Superficial  Division  of  the  External  Os. — In  endotrachelitis,  with  a  nar- 
row external  os  and  dilated  cervical  cavity,  the  retention  of  the  acrid, 
purulent  discharge  maintains  the  catarrh  and  inevitably  entails  sterility. 
It  is  therefore  indicated  to  enlarge  the  external  os  by  dilatation  or  incision, 


294 


MINOR    GYNECOLOGICAL    MANIPULATIONS. 


the  latter  being  decidedly  more  effectual  and  permanent.  It  can  be  per- 
formed with  an  ordinary  bistoury,  or  better  with  a  long,  straight-bladed 
scissors,  care  being  taken  not  to  cut  into  the  vaginal  pouch  with  the  outer 
blade  ;  or  better  still  with  a  metrotome,  the  blades  of  which  cut  on  either 
side  on  being  withdrawn. 

There  need  be  no  fear  of  profuse  hemorrhage  from  these  incisions, 
unless  they  are  made  unnecessarily  deep.  A  quarter  of  an  inch  in  each 
direction  will  generally  suffice  to  make  an  orifice  quite  large  enough  for 
all  therapeutical  and  practical  purposes.  The  advantage  of  making  a  cru- 
cial incision  is  that  the  os  remains  open  and  its  lips  do  not  touch,  as  is 
generally  the  case  when  only  a  bilateral  incision  has  been  made.  The  ap- 
pearance of  the  OS  after  crucial  incision  and  immediate  dilatation  with  a 
steel  dilator  is  shown  in  the  accompanying  cut  (Fig.  136).  As  soon  as  the  cir- 
cular fibres  of  the  external  os  are  divided,  the  cervix 
retracts  and  becomes  slightly  shorter  and  broader. 
This  is  a  valuable  result  in  sterility  from  conical 
cervix.  When  the  crucial  incision  has  been  made, 
I  always  introduce  a  steel  two-branched  dilator  or 
uterine  dressing-forceps,  and  dilate  the  orifice  thor- 
oughly, rupturing  the  circular  fibres  of  the  cervix 
and  temporaril}'  paralyzing  them  (as  in  hyper-dis- 
tention  of  the  sphincter  ani).  Having  then  swabbed 
out  the  blood  and  obtained  a  view  of  the  endotra- 
chelian  mucous  membrane,  I  apply  whatever  agent 
(iodine,  nitrate  of  silver,  carbolic  or  nitric  acid,  cu- 
rette) appears  indicated,  and  introduce  a  plug  of  cotton  smeared  with  vase- 
line for  the  purpose  both  of  guarding  against  any  possible  secondai-y  hem- 
orrhage, and  of  keeping  the  orifice  open.  This  plug  is  introduced  on  a 
Sims  slide-applicator  (see  Fig.  108)  up  to  the  internal  os,  and  then  left  in 
the  cervical  canal  by  pushing  it  from  the  apjjlicator  by  the  metal  slide 
shown  in  the  figure.  In  doing  this  it  is  generally  well  to  steady  the  cervix 
by  a  tenaculum  hooked  into  the  anterior  lip.  On  removing  the  tenaculum, 
care  should  be  taken  not  to  hook  out  the  p]ug  with  it.  The  size  of  the 
plug  should  of  course  be  proportionate  to  the  width  of  the  canal,  and  it 
should  project  but  very  little  from  the  os,  or  it  is  liable  to  slip  out  or  be 
wiped  out  by  contact  with  the  vaginal  wall.  This,  howevei',  may  be  avoid- 
ed by  placing  a  disk  tampon  over  the  cervix.  The  plug  and  the  tampon 
both  have  strings  attached  to  permit  their  removal  by  the  patient  after 
from  twenty-four  to  thirty-six  hours.  If  the  cervix  appears  particularly 
vascular,  it  is  well  to  tamjDon  the  vagina  more  thoroughly  and  remove  the 
tampons  next  day,  introducing  a  new  supply.  The  cervical  plug  should 
be  left  in  a  day  or  two  longer. 

This  plugging  of  the  cervical  canal  may  be  repeated  every  other  day 
for  a  week  or  two  until  the  canal  appears  to  retain  the  desired  width  and 
any  cicatricial  contraction  following  the  incisions  has  been  prevented.  The 
plugs  may  be  soaked  in  any  agent  chosen  for  the  case — iodine,  carbolic 
acid  and  glyceiine,  or  impure  carboHc  acid,  being  the  best  agents  for  this 


Fig.    1£6.— External 
larked     by     Crucial 
(P.  F.  M.). 


DIVISION  OF  IN-TRAVAGIlSrAL  PORTION  OF  CERVIX.  295 

purpose,  and  the  cure  of  the  catarrh  is  thus  effected,  together  with  the  di- 
latation of  the  orifice. 

I  have  of  late  i)i'actised  a  plan  first  mentioned  to  me  by  Professor 
Fritsch,  formerly  of  Halle,  now  Spiegelberg's  successor  at  Breslau,  which 
consists  in  hooking  up  each  little  flap  of  lip  between  the  four  shallow  hx- 
cisions  in  the  crucial  operation  and  trimming  it  off  with  sharp  scissors,  so 
as  to  leave  a  smooth-bordered  round  os  ;  cicatricial  contraction  is  thus 
almost  surely  prevented,  especially  if  occasional  gentle  dilatation  is  prac- 
tised until  complete  cicatrization  has  taken,  place  (see  Figs.  137  and  138). 


Fig.  137. — External  Os  with  Dotted  Lines  show-        Fig.  138. — External  Os  showiner  Funnel  Shape 
ing  Limits  oi:  Flaps  to  be  Trimmed  (P.  F.  M.).  after  Trimming  ofE  o£  Flaps  (P.  F.  M.). 

These  incisions  of  the  external  os  are  not  dangerous,  and  accidents, 
such  as  hemorrhage,  inflammation,  or  septic  infection,  very  rarely  follow 
them.  I  am  therefore  in  the  habit  of  performing  them  at  my  office  or  the 
outdoor  clinic.  Still,  as  with  all  active  measures  to  the  uterus,  no  matter 
how  trifling,  it  should  be  borne  in  mind  that  an  accident  may  occur  when 
least  expected.     No  reasonable  precaution  should  therefore  be  neglected. 

Free  DI\^SI0N  of  the  Intkavaginal  Portion  of  the  Cervix. 

This  operation  consists  in  incising  the  portion  of  the  cer-vdx  which  pro- 
jects into  the  vagina  up  to  the  vaginal  insertion,  cutting  entirely  through 
the  part  from  the  cervical  cavity  to  and  through  the  vaginal  mucous  mem- 
brane covering  it.  This  division  may  be  either  bilateral,  quadrilateral 
(crucial),  or  radiating  (five  or  six  incisions,  according  to  Kehrer's  method). 
If  more  than  four  incisions  are  made,  the  additional  cuts  will  not  be  car- 
ried entirely  through  the  part. 

The  special  indications  of  this  operation  are  to  open  the  narrow,  rigid 
external  os  and  the  lower  portion  of  the  cervix  for  the  introduction  of  the 
finger,  or  instruments,  or  the  removal  of  tumors.  In  these  cases  it  is  gen- 
erally not  necessary  to  incise  the  internal  os  also,  because  that  canal  ■  is 
usually  dilated  if  there  be  a  tumor  in  the  uterine  cavity,  and  if  a  digital 
examination  or  intra-uterine  application  is  merely  intended  the  orifice  can 
be  forcibly  expanded  by  the  finger  or  dilators  in  a  few  moments.  While 
the  circular  fibres  at  the  internal  os  constitute  the  most  constricted  and 


296  MIN-QR    GYNECOLOGICAL    MANIPULATIONS. 

least  jdelding  portion  of  the  uterine  canal,  tliey  are  nevertheless  readily- 
dilated  by  steady  pressure  from  below  if  the  patency  of  the  lower  portion 
of  the  cervical  canal  permits  that  pressure  to  be  made  directly  against  the 
contracted  spot.  In  case  of  need,  however,  the  internal  os  may  also  be 
diAided  in  the  manner  hereafter  to  be  described. 

Some  operators  prefer  this  deep  division  of  the  cervix  to  gradual  dila- 
tation by  tents  in  all  operations  for  the  removal  of  intra-uterine  growths  ; 
others  condemn  it  as  an  unnecessary  mutilation.  Whenever  there  is 
danger  in  delay  (as  in  hemorrhage  from  fibroids  or  malignant  growths  in 
the  uterine  cavity,  or  when  a  sloughing  fibroid  calls  for  immediate  re- 
moval) the  bloody  dilatation  seems  indicated.  When  there  is  no  reason 
for  haste,  it  is  a  matter  of  habit  and  fashion,  to  a  great  degree,  which 
method  is  chosen.  Eecently  Professor  Schroeder,  of  Berlin,  has  advocated 
these  free  incisions  for  all  cases  where  the  uterine  cavity  is  to  be  thoi'oughly 
opened.  He  claims  rapidity  and  safety  for  the  method,  and  avoids  subse- 
cj^uent  mutilation  by  uniting  the  lips  of  the  incised  wounds  by  sutures  as  soon 
as  the  indication  for  which  they  were  made  has  been  fulfilled.  The  danger 
of  wounding  the  circular  artery  which  often  runs  close  to  the  junction  of 
vagina  and  cervix  should  be  borne  in  mind.  Besides,  every  such  fresh  wound 
is  liable  to  be  the  channel  through  which  septic  germs  enter  the  system. 

The  operation  is  performed  by  exposing  the  cervix  through  a  Sims  or 
Simon's  speculum,  seizing  it  firmly  with  the  tenaculum  and  drawing  it 
down  as  near  the  vulva  as  feasible.  The  pointed  blade  of  a  straight  scis- 
sors is  then  passed  into  the  cervical  canal  until  the  other  blade  almost 
touches  the  vaginal  roof  on  one  side  of  the  cervix,  and  the  intervening  tis- 
sues are  divided  with  one  sharp  stroke.  The  scissors  are  now  turned  to 
the  other  side  and  the  operation  repeated ;  and  so  on  with  the  anterior  and 
posterior  lijDS,  if  a  quadrilateral  incision  is  to  be  made.  If  additional  shal- 
low incisions  are  required  to  open  the  canal  still  more,  a  long  blunt-pointed 
knife  is  introduced  and  the  cer\dx  divided  about  half-way  through  in  two 
or  more  places.  The  divided  flaps  will  generally  curl  out  shghtly,  and 
readily  admit  the  finger  or  a  steel  divergent  dilator  to  complete  the  dilata- 
tion beyond  the  level  of  the  vaginal  insertion. 

The  hemorrhage  is  liable  to  be  quite  profuse,  but  will  be  arrested  by 
the  pressure  exerted  by  the  dilating  finger  or  instruments.  If  the  canal 
is  to  be  left  oj)en,  a  carbohzed  cotton  tampon  or  plug  (soaked  in  a  mixture 
of  persulphate  of  iron  and  glycerine,  and  squeezed  dry,  or,  what  is  equally 
good  and  much  cleaner,  a  saturated  solution  of  alum)  should  be  inserted 
by  forceps  or  on  a  slide-aj^plicator  and  the  incised  canal  tightly  packed  ; 
besides,  the  hemostatic  tamponade  of  the  vagina  should  be  added  as  a  pre- 
caution. The  vaginal  tampons  should  be  removed  after  twenty-four  hours, 
the  cervical  plug  not  until  it  begins  to  loosen  and  come  away  by  itself. 
Carbolized  irrigation  of  the  vaginal  and  uterine  cavity  should  precede  the 
introduction  and  follow  the  removal  of  these  tampons. 

This  operation,  be  it  understood,  is  not  intended  so  much  as  a  cure  of 
a  stenosis  of  the  cervix,  than  as  a  necessary  prehmiuary  to  operations  on 
the  uterine  cavity. 


DISCISSIOI^    OF    THE    CERVICAL    CAT^AL. 


297 


Discission  of  the  Cekyical  Canal. 


Bilateral  Division  [Simpson's  Operation). — By  discission  of  the  cervical 
canal  is  meant  the  division  of  the  whole  canal  from  and  through  the  ex- 
ternal, to  and  through  the  internal  os. 

This  oj^eration  was  first  performed  by  Sir  James  Simpson,  and  con- 
sisted in  passing  his  metrotome  through  the  internal  os,  opening  and 
rapidly  withdrawing  it  with  expanded  blades;  it  was  then  reintroduced 
with  the  cutting  edge  turned  to  the  opposite  side,  and  the  same  maneuvre 
repeated.  In  this  way  a  uniform  division 
of  the  internal  and  external  os  was  effected 
and  the  canal  made  of  the  same  width 
throughout.  By  this  operation  the  cervi- 
cal canal  is  divided  bilaterally,  as  shown 
in  Fig.  139.  To  distinguish  it  from  other 
methods,  this  operatien  has  been  named 
after  its  inventor  and  is  known  as  Simp- 
son's operation  for  division  of  the  cervix 
uteri.  Simpson  was  in  the  habit  of  per- 
forming it  in  his  consulting-room,  simply 
wiping  out  the  incised  canal  with  a  brush 
dipped  in  a  solution  of  perchloride  of  iron. 
As  a  result,  a  number  of  patients  had  se- 
vere hemorrhage  and  some  died  of  metro- 
peritonitis, but  unfortunately  no  statistics 
of  these  oj)erations  were  ever  published. 
This  bilateral  incision  of  the  cervical  canal 
is  "applicable  only  to  cases  in  which  the 
intra-vaginal  portion  of  the  cervix  is  nor- 
mally develojDed,  in  which  the  anterior  and 
posterior  segments  of  the  cervix  are  symmetrical  with  the  os,  pointing 
usually  toward  the  posterior  wall  of  the  vagina."  (Sims.)  It  is  performed 
only  for  constriction  of  the  cervical  canal,  and  the  consequences  thereof, 
dysmenorrhea  and  sterility.  Its  object  is  solely  to  enlarge  the  canal,  to 
render  it  jDatent  for  the  menstrual  blood  and  the  seminal  fluid. 

The  degree  of  constriction  of  the  cervical  canal  which  would  call  for  en- 
largement by  the  knife  is  largely  relative,  or  is  a  matter  of  opinion  as  to 
the  absolute  necessity  of  a  patulous  canal  for  the  joossibiHty  of  conceiDtion. 
Peaslee  believed  that  the  internal  os  should  be  divided  when  a  sound  of 
one-eighth  of  an  inch  diameter  is  unable  to  pass,  and  that  the  external  os 
is  too  small  when  its  diameter  measures  but  one-sixth  of  an  inch,  or  less. 
As  a  rule,  we  may  assume  that  a  cei'vical  canal  which  readily  permits  the 
passage  of  a  Simpson's  sound  is  sufficiently  wide  to  admit  spermatozoa,  and 
allow  the  menstrual  blood  to  escape.  But  there  are  cases  in  which  the 
sound  is  readily  introduced,  although  the  external  os  appears  very  small 
to  the  touch  and  the  eye  ;  in  these,  the  lips  of  the  os  are  generally  flabby, 


Lines  of  Incision  made  by 
Greenhalgh's  Metrotome  in  Bilateral  In- 
cision of  the  Cervical  Canal.    (Hewitt.) 


298  MINOR    GYNECOLOGICAL   MAISTIPULATIONS.     , 

tliey  fall  together,  and  thus  quite  as  effectually  close  the  external  os,  as 
though  that  orifice  were  really  contracted.  Again,  the  sound  easily  passes 
through  a  portion  of  the  canal,  and  is  arrested  near,  or  at  the  internal  os,  by 
rugosities,  pockets  in  the  hyperj^lastic  mucous  membrane,  even  though  the 
canal  is  perfectly  straight  and  quite  wide  enough  to  admit  the  sound,  which 
finally  slips  over  the  obstruction  and  glides  into  the  uterine  cavity.  But 
these  rugosities  may,  by  dropping  together — dovetailing,  as  it  were — 
present  an  obstacle  to  the  spermatozoa,  if  not  to  the  menstrual  blood. 
These  two  conditions,  therefore,  may  be  considered  relative  indications 
for  discission  ;  they  constitute  a  practical,  if  not  actual,  contraction  of  the 
canal. 

It  is  therefore  well  to  formulate  the  indications  for  discission  both  on 
the  physical  condition  of  the  uterine  canal,  and  the  symptoms  of  obstruc- 
tion manifested.  Thus,  even  though  the  external  os  be  apparently  large 
enough,  if  the  cervical  cavity  be  unduly  dilated,  as  by  retention  of  secre- 
tion, it  is  fair  to  assume  that  the  orifice  is  relatively  too  small,  and  should 
be  enlarged  ;  and  so  also  with  the  internal  os  and  uterine  cavity.  I  have 
frequently  been  compelled,  for  want  of  other  appreciable  causes,  to  assume 
that  the  dysmenorrhea  or  sterility  was  due  to  some  obstruction  in  the 
uterine  canal,  although  the  latter  appeared  large  enough  ;  and  have  then 
thought  myself  justified  in  dilating  the  canal,  simply  because  that  seemed 
the  best  manner  of  overcoming  the  difiiculty. 

A  peculiar  rigid  condition  of  the  normally  large  external  os  is  spoken 
of  by  Chrobak  as  an  apparent  cause  of  sterihty,  and  I  have  made  the  same 
observ^ation  in  women  in  whom  the  cervix  had  been  lacerated  and  the  hps 
of  the  gaping  os  were  rigid  and  undilatable  through  cicatricial  induration. 
It  seems  as  though  mere  patency  of  the  cervical  canal  is  not  sufficient  to 
insure  conception  ;  the  consistence  of  the  cervical  tissues  must  be  favora- 
ble to  a  dilatation  of  the  os  under  the  impulse  of  sexual  excitement,  and 
such  a  cervix  of  course  does  not  need  incision.  The  softening,  alterative 
effects  of  sponge-tents,  iodine  applications,  glycerine  tampons,  and  hot- 
water  injections  would  restore  the  elasticity  of  the  os. 

A  long  conical  cervix,  with  narrow  external  os  and  elongated  uterine 
canal,  may  be  benefited  by  combining  the  bi-  or  quadrilateral  deep  incision 
of  the  external  os  with  the  discission  of  the  internal  os.  The  deejD  division 
of  the  external  os  causes  the  lips  of  the  cervix  to  roll  out,  and  thus  shortens 
the  cervix.  This  shortening  may  not  suffice,  howevei-,  and  the  amputation 
of  a  portion  of  the  cervix  may  be  required. 

The  manner  of  performing  this  ox)eration — Simpson's  bilateral  division 
of  the  cervix  through  the  whole  canal — as  modified  and  improved  up  to 
the  pi-esent  time,  chiefly  by  Sims,  is  as  follows  :  It  is  not  necessary  to  an- 
esthetize the  patient,  for  the  pain  is  comparatively  slight ;  but  as  the 
operation  should  invariably  be  done  at  the  home  of  the  patient,  it  may  be 
as  well  to  put  her  under  ether,  if  she  is  at  all  nervous.  The  cervix  is  ex- 
posed through  Sims'  speculum  (another  will  not  do  as  well  for  this  oper- 
ation), and  seized  as  usual  with  the  tenaculum.  The  direction  of  tbe 
utei'ine  canal  is  ascertained  by  the  probe,  and  the  metrotome,  with  its 


DISCISSION    OF    THE    CERVICAL    CANAL.  209 

blades  hidden,  is  passed  up  transversely  through  the  internal  os.  The 
blades  are  then  opened  by  the  screw  or  pressure  mechanism  in  the  handle 
(the  expansion  of  the  blades  and  their  cutting  limit  having  been  previously 
noted  and  the  screw  regulated  accordingly)  and  the  instrument  is  gently 
withdrawn. 

In  this  country  the  metrotomes  with  hidden  blades  are  but  little  used, 
but  the  knife  introduced  by  Sims  is  almost  universally  employed.  It  con- 
sists of  a  stout  handle  in  which  several  blades  of  different  width  and  shape 
are  fixed  at  will  by  a  compression  apparatus,  as  a  needle  is  seized  in  the 
needle-holder.  The  blade  to  be  used  is  fixed  in  the  handle  at  an  angle 
corresponding  to  the  direction  of  the  uterine  canal,  and  gently  insinuated 
through  the  internal  os.  One  side  of  the  cervix  is  then  cut  through  to  the 
external  os  ;  the  knife  is  now  introduced  again,  and  the  other  side  divided. 
A  large  Peaslee's  sound  is  now  inserted,  and  the  dimension  of  the  canal 
measured.  If  it  is  freely  passable  for  a  sound  one-fourth 
of  an  inch  in  diameter,  the  ojjeration  may  be  said  to  be 
concluded.  If  any  obstruction  is  felt,  the  knife  is  again 
introduced  and  the  incisions  are  deepened.  The  cuts 
should  be  made  with  a  gentle  sawing  motion.  When 
the  incision  is  sufficiently  large,  a  stout  dilator  is  intro- 
duced (Sims  jDreferred  his  three-bladed,  and  it  probably 
is  the  best  for  this  purpose)  and  the  blades  are  separated 
until  it  shows  an  expansion  of  one-half  to  one  inch  (the 
limit  of  the  dilator).  The  cendx  should  not  be  drawn 
down  and  fixed  with  the  tenaculum,  because  when  the  di- 
lator is  expanded  the  uterus  will  fly  away,  and  the  dilator 

,    '-       ,,  .  T.    •     -,      ,1        ,  1    +1        T1    ^  Fig.  140.-Sims- Hard- 

escape  irom  the  cervix,     it  is  better  to  pusn  tne  dilator   nibber  piug  for  niscis- 

1       IT        f        -I  -^    n  ii  ji  j_  ^ion  of  thd  Cervix. 

up  to  the  fundus,  and  then  gently  press  the  uterus  up- 
ward with  it  until  the  vagina  is  extended  to  its  greatest  length,  and  make 
the  dilatation.     The  uterus  then  cannot  escaj^e. 

The  canal  having  been  thoroughly  dilated,  the  cervix  is  seized  with 
the  tenaculum,  drawn  down,  and  a  smooth  glass  or  hard-rubber  plug 
(Fig.  140)  introduced  to  arrest  hemorrhage  and  maintain  the  canal  patent. 
This  plug  is  two  inches  long,  and  is  made  of  different  sizes,  graduated  by 
the  English  measure  from  No.  11  to  19.  The  large  base  prevents  the  plug 
from  slipping  into  the  uterus,  and  compresses  the  bleeding  wounds  at  the 
exposed  os.  If  the  canal  is  not  large  enough  to  admit  at  least  the  No.  11 
jDlug,  it  must  be  incised  or  dilated  still  more.  Once  introduced,  the  plug 
is  held  in  position  by  a  tampon  soaked  in  saturated  solution  of  alum  and 
placed  directly  over  the  cervix.  The  vagina  is  then  tamponed  in  the  man- 
ner described  for  hemostasis,  the  upper  layers  being  soaked  in  alum  water, 
the  lower  in  carbolized  water. 

I  have  used  with  much  satisfaction,  after  forcibly  dilating  the  uterus 
with  steel  divergent  dilators  for  dysmenorrhea  and  sterility  with  or  without 
anteflexion,  a  glass  stem  with  bulbous  tip,  the  device  of  Dr.  W.  M.  Cham- 
berlain, of  New  York,  leaving  it  in  utex'o  for  periods  varying  fi'om  a  week 
to  several  months. 


300  MINOR    GYNECOLOGICAL    MANIPULATIONS. 

If  the  tampon  interferes  with  micturition,  or  gives  pain,  the  lower 
layers  may  be  removed  after  a  few  hours.  The  patient  is  kept  in  bed,  very 
quiet  for  forty-eight  houi's,  the  urine  being  drawn  with  the  catheter.  She 
must  not  sit  up  in  bed  or  strain,  lest  the  plug  be  dislodged.  The  lower 
layers  of  the  tampon,  up  to  the  vaginal  vault,  may  be  removed  on  the  third 
or  fourth  day,  but  if  the  upper  layers  look  compact  and  fresh  they  should 
not  be  disturbed  for  two  or  three  days  longer.  If  there  is  a  fetid  dis- 
charge or  rise  of  temperature,  all  the  tampons  should  be  at  once  removed, 
the  vagina  cleansed  with  carbolized  water,  and  a  carbolized  cotton  tampon 
again  placed  over  the  plug  in  the  cervix.  The  plug  may  be  left  in  until 
the  tenth  day,  although  usually  the  fifth  or  sixth  day  will  suffice.  The 
patient  remains  in  bed  for  ten  days,  and  is  then  transferred  to  the  sofa  ; 
she  must  not  leave  her  room  until  the  next  menstrual  period  has  passed. 
The  bowels  should  be  regulated,  after  having  been  kept  constipated  'for 
several  days  after  the  operation.  After  the  first  movement  it  is  import- 
ant to  see  whether  the  tampon  has  been  displaced,  and  if  necessary 
readjust  it. 

In  former  years  Dr.  Sims  tamponed  the  cervical  cavity  after  discission 
with  a  cotton  plug  soaked  in  the  persulphate  of  iron  solution.  But  this 
was  nasty  work,  j)i'oduced  coagula,  and  aided  in  contracting  the  canal 
again.  The  pressure  of  the  glass  or  rubber  plug  is  quite  as  effectual  in 
controlling  hemorrhage,  more  so  in  keej)ing  the  canal  open,  and  much 
cleaner  and  neater  in  every  respect. 

To  remove  the  tampon  layers  one  by  one  without  displacing  the  upper 
layers,  which  are  not  to  be  distui'bed,  a  useful  instrument  has  been  de- 
vised by  Sims,  called  the  tampon-screw  (Fig.  97).  It  is  of  steel,  with  a 
double  corkscrew  tip,  which  is  screwed  into  each  cotton  disk  separately, 
and  while  the  finger  of  the  other  hand  holds  down  the  bulk  of  the  tam- 
pons, the  screw  removes  the  disk. 

To  insure  patency  of  the  canal  frequent  examination  is  necessary,  the 
finger  being  thrust  gently  into  the  cervix  as  far  as  it  will  reach.  Dilata- 
tion with  sound  or  dilators  may  also  occasionally  be  needed. 

Antero-posterior  Division  [Sims'  Operation). 

The  antero-posterior  discission  of  the  cervix  consists  in  dividing  the 
intra-vaginal  jDortion  in  the  median  line,  either  anteriorly  or  j)osteriorly, 
or  both,  and  extending  the  incision  upward  through  the  internal  os.  It  is 
indicated  in  an  entirely  different  class  of  cases  from  the  bilateral  opera- 
tion, viz.,  in  cases  where  the  intra-vaginal  portion  of  the  cervix  is  un- 
equally or  abnormally  shaj)ed,  the  posterior  segment  being  longer  than 
the  anterior,  and  the  body  of  the  uterus  anteflexed.  The  bilateral  op- 
eration, it  will  be  remembered,  is  suitable  for  cases  of  reg-ular,  uniform 
development  of  the  cervix,  without  ante-  or  retroflexion,  where  the  only 
indication  for  operation  is  the  narrowness  of  the  uterine  canal  or  the 
rigidity  of  the  cervix.  The  so-called  conical  cervix  forms  a  large  con- 
tingent of  the  cases  requiring  this  bilateral  operation. 


DISCISSION    OF    THE    CERVICAL    CANAL. 


301 


The  cases  to  which  the  posterior  section  of  Sims  is  sjiecially  adapted 
are  illustrated  in  the  cuts  Figs.  141  to  l^G,  taken  from  Sims. 

To  perform  this  operation  in  a  normally  developed  cervix  would  be 
entirely  improper  and  unscientific. 
These  figures  represent  different 
degrees  of  anteflexion,  both  of  the 
body  and  of  the  cervix.  The  ob- 
ject of  the  operation — to  straight- 
en the  uterine  canal — is  at  once 
apparent  from  the  direction  of  the 
dotted  lines. 

Dr.  Sims  lays  particular  stress 
on  the  unequal  develoj)ment  of  the 
cervix  in  these  cases,  the  long, 
often  thick  and  gristly  posterior 
lip  forming  a  direct  obstacle  to 
the  ingress  of  the  spermatozoa. 
The  rationale  of  his  plan  of  di\id- 
ing  the  posterior  lip  and  making 
a  large  opening  to  the  uterine  canal — an  opening  which,  being  situated 
opposite  the  deepest  portion  of  the  posterior  vaginal  wall,  is  nearest  the 
pool  of  semen  collected  there  after  coition — is  certainly  plausible,  and  has 
been  verified  by  many  successes.  That  Simpson's  operation  would  not 
achieve  the  same  result  is  obvious  on  comparing  the  figures.  The  distinc- 
tion between  these  two  operations,  bilateral  and  antero-posterior  section, 
has  only  recently  been  emyjliasized  by  Sims  in  an  article  on  the  Treatment 
of  Stenosis  Uteri,  published  in  Vol.  III.  of  the  "  Transactions  of  the  Ameri- 
can Gynecological  Society,"  from  which  the  illustrations  credited  to  Sims 


Fig.  141. — Lines  of  Incision  in  Anteflexion  of  the 
most  Marked  Degree  (Sims). 


Fig.  142.— Lines  of  Incision  in  Anteflexion  with  Retro- 
version (Sims). 


Fig.  143.— UtL-rus  with  Faulty  Direction  of 
External  Oa.  a,  axis  of  vagina  :  b,  normal 
direction  of  external  os ;  c,  present  direction 
of  external  os  ;  cl,  line  of  incision  (Sims). 


in  this  section  are  taken.  As  Sims'  operation  and  views  in  this  matter  had 
been  misunderstood  until  the  explanation  contained  in  the  above  article,  I 
have  been  careful  to  reproduce  the  operation  precisely  as  he  gives  it  there. 


502 


MINOR    GTl^ECOLOGICAL    MANIPULATION'S. 


The  manner  of  performing  tliis  operation  is  as  follows  :  The  direction, 
curve,  and  dimensions  of  the  uterine  canal  having  been  thoroughly  studied, 
the  cervix  is  exposed  through  Sims'  speculum,  the  anterior  lip  seized  with 
a  tenacidum,  and  the  straight  blade  of  Sims'  metrotome  "  set  in  the  handle 


Fig.  144. — Division  of  Posterior  Lip 
in  Anteflexed  Cervix  (Sims). 


Fig.  145. — Lines  of  Incision  in  Acute  Flexion 
at  the  Os  Internum  (Sims). 


"with  blade  backward,  is  passed  into  the  cervical  canal  until  the  point  passes 
through  the  internal  os.  If  the  flexion  is  marked,  the  knife  will  not  pass 
easily ;  a  fine  grooved  director,  bent  at  the  required  curve,  should  then  be 
introduced  and  the  knife  passed  in  along  the  groove.  The  director  is  then 
removed  and  the  constriction  divided  ;  with  gentle  cutting  motion  the 
posterior  portion  of  the  cervix  is  spht  in  a  straight  line  back  from  the  os 
tincae  nearly  to  the  insertion  of  the  vagina.  The  knife  is  then  withdrawn, 
the  blade  is  turned  in  the  handle  so  as  to  cut  anteriorly,  and  again  passed 
into  the  canal  of  the  cervix  as  before,  and  in  withdrawing  it  the  obstruc- 


FiG.  146. — Utems  with  Cervix  Equally  Developed, 
but  with  Constricttid  Canal,  Suitable  for  Simpson's 
Operation  (Sims). 


Fig.  147. — Bilateral  Division  of  Os :  a,  v. 
Lines  of  Incision :  c.  Size  of  Os  Twelve 
Mouths  after  Operation  (Sims). 


tion  at  the  point  of  greatest  flexure,  at  the  os  internum,  is  incised  anteri- 
orly. The  blood  is  sponged  away,  and  the  trivalve  dilator  is  used,"  and 
the  plug  introduced,  and  the  wound  dressed  as  already  described.  Sims 
formerly  used  the  scissors  for  splitting  the  posterior  hp,  but  now  prefers 


DISCISSION    OF    THE    CERVICAL    CANAL. 


303 


the  knife  for  tbis  also.     The  passage  of  the  knife  through  the  internal  os 
of  an  acutely  flexed  canal  is  often  very  difficult. 

The  direction,  length,  and  depth  of  the  incisions  are  shown  by  the  dot- 
ted lines  in  the  cuts,  and  therefore  need  not  be  further  described. 

Accordingly  as  the  operation  of  posterior  section  is  done  for  anteflex- 
ion of  the  cervix,  or  anteflexion  of  the  body,  Emmet  incises  only  the  pos- 
terior lip  and  the  posterior  wall  up  to  the  internal  os,  or  cuts  through  the 
anterior  wall  and  through  the  internal  os  also.  The  lines  of  incision  are 
shown  in  Figs.  148  and  149.     . 

Emmet  uses  the  scissors  for  the  first  incision,  and  completes  the  oper- 
ation with  the  knife.  The  probe  is  carried  into  the  canal  as  a  guide  to 
scissors  and  knife.  Emmet  tampons  the  cervix  with  glycerized  cotton 
instead  of  the  plug. 

The  after-treatment  is  precisely  the  same  as  after  Simpson's  operation. 

The  clangers  of  these  two  operations,  Simpson's  and  Sims',  are  pretty 
nearly  equal.  After  both  we  may  have  serious  hemorrhage,  peritonitis  or 
cellulitis,  septicemia,  death.  Sims  admits  two 
deaths,  one  after  his,  the  other  after  the  bUateral 
incision,  among  somewhat  less  than  a  thousand 
operations.  He  also  speaks  of  t-wo  instances  of 
hemorrhage  from  the  circular  artery,  which  was 

BO  severe  as  to  require  a  suture-ligature  to  be     / "—-    W  I  ^^^:<^ 

passed  through  the  cervix  and  tied  over  the  ante-      ^     ^  '^^   ' 

rior  edge  of  the  os.     The  artery  was  cut  by  the 
anterior  incision.     Dr.  Emmet  has  also  met  with 
this  accident.     Of  one  hundred  and  five  cases 
which  the  latter  operated  on  in  his  private  hos- 
pital and  the  New  York  Woman's  Hospital,  there      j-i^  148.— Lines  of  incision  in 
were  three  deaths  from  peritonitis,  in  each  of     flexure  of  the  cervix  (Emmet), 
which  imprudence  on  the  part  of  the  patient  might  fairly  be  considered 
the  chief  factor.      A  number  of  cases  of  cellulitis  occuiTed,  but  the  exact 
figure  is  not  given. 

Since  he  began  the  use  of  his  hard  plug,  Sims  was  not  troubled  with 
hemorrhage  after  these  operations  ;  and  Emmet  states  that  the  proper  pre- 
cautions adopted  by  him  since  the  above-mentioned  accidents  (such  as  anti- 
septic treatment  of  instruments  and  wound,  watchfulness,  performance  of 
operation  only  at  a  spot  where  a  physician  can  be  immediately  procured  in 
case  of  need)  have  prevented  a  recurrence  of  either  hemorrhage,  peri- 
tonitis, or  severe  cellulitis. 

A  compilation  by  Beigel  of  900  cases  by  Tanner,  Ballard,  Sims,  Em- 
met, and  Greenhalgh,  shows  5  cases  of  death  from  peritonitis,  3  sevei'e 
hemorrhages,  and  6  instances  of  cellulitis.  Of  German  authors,  Hegar  and 
Kaltenbach  had  2  deaths  in  nearly  300  cases,  which  occurred  before  they 
began  to  use  antiseptic  precautions  ;  Martin,  1  death  and  several  hemor- 
rhages in  386  cases  ;  Carl  Braun,  291  cases  with  1  hemorrhage  and  1  cel- 
luhtis  ;  Gustav  Braun,  107  cases  with  4  of  peritonitis  ;  Kehrer,  86  opera- 
tions with  4  cases  of  celluhtis  and  peritonitis,  and  1  death ;  Chrobak,  250 


304 


MINOR    GYNECOLOGICAL    MANIPULATIONS. 


cases,  with  2  hemorrhages  and  2  attacks  of  cellulitis,  up  to  1876,  since 
then,  50  operations  without  accident.  Thus,  among  2,425  collated  cases, 
together  with  the  unnumbered  ones  of  Sims,  certainly  in  all  3,500,  we  have 
9  deaths.  The  cases  of  severe  peritonitis,  cellulitis,  and  hemorrhage  are 
not  recorded  with  sufficient  accuracy  to  be  of  value,  but  were  certainly  as 
high  as  twenty  per  cent,  all  together.  One  great  defect  of  these  statistics 
is  that  it  is  not  mentioned  in  many  of  the  foreign  cases  whether  only  the 
external  os,  or  the  internal  os  also  was  incised.  This  may  account  for  Carl 
Braun's  want  of  accidents,  for,  of  course,  the  mere  division  of  the  external 
OS  is  but  a  trifling  matter.  The  depth  of  the  incision  through  the  internal 
OS  depends,  in  Sims'  method,  greatly  upon  the  dexterity  and  experience 
of  the  operator,  since  only  a  practised  finger  can  tell  how  deep  and  where 
to  cut.  As  a  rule,  it  is  better  to  err  on  the  safe  side  and  not  cut  too  deep, 
and  if  the  o]perator  is  not  rashly  bold,  this  is  generally  the  case.  Only  a 
very  practised  ojoerator,  Hke  Sims  himself,  will  be  able  to  gauge  precisely 
how  deep  he  may  cut  without  wounding  the  circular  artery  or  the  perito- 
neum. If  the  mechanically  working  metrotomes 
are  used,  the  cut  may  be  too  small  if  one  does 
not  allow  for  the  elasticity  of  the  tissues,  and 
too  large  if  the  screw  is  set  so  as  to  expand  the 
blades  more  widely  in  anticipation  of  this  elas- 
ticity. The  knife  is  therefore  thought  to  be  the 
safest  instrument. 

"With  the  proper  precautions,  and  carefully 
omitting  all  cases  to  be  mentioned  under  counter- 
indications,  the  oj^eration  of  division  of  the  cer- 
vical canal  and  internal  os,  according  to  Simpson 
or  Sims,  may  be  considered  as  not  especially 
dangerous.  Sims  contends  that  it  is  no  more 
dangerous  than  forcible,  rapid,  or  gradual  dilatation,  while  much  more 
effectual.  His  wonderful  dexterity  no  doubt  accounts  for  his  good  results 
and  his  immunity  from  accidents  since  the  adoption  of  his  improved 
method,  as  above  described.  An  inexperienced  operator  will  j)i'obably  do 
far  less  damage  with  dilatation  by  non-cutting  instruments. 

The  counter-indications  are  again  the  same  as  repeatedly  stated  for  all 
manipulations  on  the  uterus  :  all  acute,  subacute,  and  chronic  inflamma- 
tory conditions  of  the  pelvic  organs  ;  purulent  discharge  from  the  uterus, 
which  might  infect  the  wound  ;  the  proximity  of  the  menstinial  period 
(one  fatal  case  by  Emmet,  and  two  severe  cases  of  cellulitis  by  Chrobak, 
were  due  to  the  performance  of  the  operation  a  few  days  before  men- 
struation). 

The  curative  value  and  permanent  benefit  of  these  operations  is  by  no 
means  assured  ;  for  statistics  of  successes,  as  regards  the  relief  of  dysmen- 
orrhea, and  chiefly  as  regards  conception,  have  not  been  furnished  by  the 
operators  whose  figures  were  quoted  above.  Frequent  isolated  cases  of 
speedy  conception,  after  the  operation,  have  been  reported  by  all  of  them, 
but  an  exact  proportion  of  successes  and  failures  has  not  been  published. 


Fig.  149. — Lines  of  Incision  in 
Flexion  of  the  Body  (Emmet). 


SUPERFICIAL    TKACHELOTOMY.  305 

Of  the  four  htindred  and  eiglity-three  discissions  (wlietber  external  os,  or  in- 
ternal OS  also,  is  again  not  stated)  performed  by  Haartmann,  Braun,  Mar- 
tin, Kehrer,  and  Chrobak,  one  hundred  and  forty-eight,  equal  to  30.7  per 
cent.,  were  successful.  But  whether  the  dysmenorrhea  or  sterility  was  cured 
is  not  stated  in  a  sufficient  number  of  cases  to  be  of  value.  A  large  and 
careful  statistical  compilation  of  the  indications,  exact  method  of  treat- 
ment, and  results  as  regards  cure  of  dysmenorrhea  and  steriHty,  by  the 
various  methods  of  bloodless  dilatation,  the  Simpson,  Sims,  and  Peaslee 
operations,  and  the  simple  division  of  the  external  os,  respectively,  Avould 
be  exceedingly  interesting  and  of  immense  practical  value. 

So  much  appears  certain  that,  ceteris  paribus,  an  open  external  os  and 
straight  and  large  cervical  canal  are  more  favorable  to  impregnation  than 
a  small  external  os  and  narrow  and  crooked  canal.  If,  therefore,  no  other 
cause  for  the  sterility  can  be  ascertained  but  a  narrow  cervical  canal,  it  is 
fair  to  assume  that  this  is  the  cause  of  the  sterility,  and  to  give  the  patient 
the  chance  of  cure  by  enlarging  it. 

The  impossibility  of  recognizing  the  cause  of  sterility  in  those  cases  in 
which  ovarian  disease  or  encapsulation  of  the  ovary  in  adhesions,  or  strict- 
ure of  the  Fallopian  tubes,  or  imperfect  maturation  of  the  ova,  are  at 
fault,  will,  of  course,  render  any  efforts  at  cure,  by  discission  or  otherwise, 
futile.  In  estimating  the  value  of  statistics  on  this  subject,  this  fact  should 
be  taken  into  consideration. 

The  great  difficulty  with  all  operations  for  dilatation  of  the  cervical  canal, 
bloodless  or  by  cutting  instruments,  is  the  persistent  tendency  of  the  canal 
to  contract  again.  Even  the  most  widely  opened  canal  will  be  found  in  a 
few  months  as  small  as  before,  and  if  cicatricial  contraction  has  chanced  to 
be  exceptionally  great,  it  may  even  be  smaller  than  before  the  operation. 
Or,  the  divided  lips  may  unite  unequally,  so  as  to  form  flajDS  which  obstruct 
the  entrance  to  the  external  os.  Or,  the  edges  of  the  enlarged  os  may  be- 
come dense,  gristly,  and  unyielding.  Or,  the  incisions  through  the  intra- 
vaginal  portion  may  have  been  so  deep,  and  the  retraction  of  the  flaps  so 
great,  that  an  eversion  of  the  cervical  mucous  membrane,  an  ectropium,  as 
after  parturition,  takes  place,  and  the  flaps  require  to  be  united  by  paring 
their  edges  and  inserting  silver  sutures,  as  devised  by  Emmet  for  puer- 
peral laceration.  Careful  attention  to  the  after-treatment  will  hinder  the 
contraction  of  the  canal,  and  avoidance  of  too  deep  or  unequal  incisions 
will  prevent  subsequent  malformation  or  ectroj)ium. 

Superficial  Trachelotomy  (Peaslee's  Operation). 

In  the  belief  that  the  two  operations  just  described,  the  deep  bilateral,- 
and  the  deep  antero-posterior  section,  were  unnecessarily  severe,  produced 
too  large  an  injury,  and  left  a  mutilated  cervix  and  gaping  os,  and  were 
furthermore  often  followed  by  seiious  and  fatal  results.  Dr.  E.  K.  Peaslee 
devised  and  practised  an  operation,  which  consisted  in  mei'ely  cutting 
through  the  external  or  internal  os,  or  both,  if  one  or  both  were  con- 
stricted, to  a  depth  sufficient  to  make  the  canal  of  the  average  ■\^idth  of  a 
20 


306  MIlSrOR    GYNECOLOGICAL    MAl^IPULATION'S. 

parous  woman.  According  to  Peaslee,  if  tlie  external  os  does  not  easily 
admit  a  sound  one-sixth  of  an  inch  in  diameter,  there  is  stenosis  as  to 
conception  ;  if  no  more  than  one-seventh  of  an  inch,  probably  also  dys- 
menorrhea. 

If  the  internal  os  readily  admits  a  sound  one- sixth  of  an  inch  in  diam- 
eter, there  is  no  absolute  but  possibly  relative  stenosis  ;  i.e.,  passage  for 
the  sound,  but  not  for  fluids.  If  a  sound  of  one-seventh  of  an  inch  is 
easily  passed,  there  is  still  no  stenosis,  unless  the  symptoms  indicate  ob- 
struction. This  is  the  normal  size  in  the  imparous  woman,  and  the  size  of 
Simpson's  sound. 

If  a  sound  but  one-eighth  of  an  inch  in  diameter  cannot  be  passed 
through  the  internal  os,  there  is  stenosis,  or  flexion. 

In  an  external  os  of  one-seventh  or  one-sixth  of  an  inch,  and  an  inter- 
nal OS  of  one-eighth  of  an  inch,  absolutely,  and  one-seventh  of  an  inch, 
relatively,  the  operation  of  superficial  trachelotomy  is  indicated.  If  con- 
gestion of  the  uterus  is  superadded  to  the  above  diameters,  the  operation 
is  still  more  called  for,  and  even  an  internal  os  of  one-seventh  of  an  inch 
may  require  division. 

The  constricted  canal  is  now  to  be  enlarged  to  the  average  size  in  the 
healthy  woman  who  has  borne  children,  which  Dr.  Peaslee  says  is  rather 
less  than  one-fourth  at  the  external  os,  and  slightly  less  than  one-fifth  of 


Fig.  150. — Uterine  Portion  of  Peaslee's  Metrotome,  with  Blade  Protruding. 

an  inch  at  the  internal  os.  He  therefore  thinks  that  an  enlargement  to 
one-fourth  of  an  inch  at  the  external,  and  one-fifth  of  an  inch  at  the  in- 
ternal OS,  is  amply  sufiicient  for  all  jDractical  purposes  for  the  relief  of 
dysmenorrhea  and  sterility.  If  congestion  is  present,  the  limit  may  be 
extended  to  one-third  of  an  inch,  and  to  nearly  one-fourth  of  an  inch, 
respectively. 

The  incisions  are  not  made  to  the  same  depth  in  every  case,  but  very 
rarely  extend  deeper  than  through  the  mucous  membi'ane  at  the  internal 
OS,  perhaps  barely  nicking  the  submucous  stratum. 

The  instrument  with  which  this  operation  is  performed  is  seen  in  Fig. 
150.  It  consists  of  a  flattened  tube  eight  inches  long  and  seven-sixteenths 
of  an  inch  wide,  except  the  terminal  one  and  three-fourths  inch,  which  has 
a  width  of  but  one-eighth  of  an  inch.  In  this  tube  a  blade  slides  easily, 
with  a  nut  and  screw  at  the  pi'oximal  end  to  gauge  the  extent  of  its  pas- 
sage into  the  cervical  canal.  The  blade  has  a  blunt  point,  and  lateral  cut- 
ting edges  for  one  and  five-eighths  of  an  inch  at  the  distal  end.  There  are 
two  blades  for  each  instrument,  the  cutting  portion  of  one  being  one- 
fourth  of  an  inch  wide,  of  the  other  three-sixteenths  of  an  inch.  If  the 
stenosis  is  confined  to  the  internal  os,  the  narrower  blade  only  is  used  ;  if 
both  ora  are  contracted,  the  wider  blade  is  passed  through  the  external, 
and  the  narrower  blade  then  through  the  internal  os.     In  decided  conges- 


SUPERFICIAL   TRACHELOTOMY. 


307 


tion  tte  wider  blade  may  be  passed  through  the  internal  os  also,  which 
will  then  easily  admit  a  sound  one-fifth  of  an  inch  in  diameter. 

The  operation  is  performed  through  the  Sims  speculum,  or  the  metro- 
tome may  be  guided  on  the  finger  like  the  sound. 

The  tube  is  passed  into  the  cervical  canal  up  to  the  shoulder,  and 
therefore  one-fourth  of  an  inch  through  the  internal  os.  The  blade  is 
then  passed  in,  having  been  previously  gauged,  and  carried  up  as  far  as 
necessary  to  divide  the  stenosis.  If  the  external  os  is  too  narrow  to  admit 
the  instrument,  it  may  be  nicked  with  a  bistoury. 

The  operation  is  not  at  all  dangerous,  and  Dr.  Peaslee  reports  having 
performed  it  many  times  in  his  office,  sending  the  patient  home  to  bed 
after  a  short  time.  Out  of  over  three  hundred  operations  he  saw  but  one 
case  of  slight  abdominal  tenderness  for  several  days,  and  twice  sHght  cel- 


PlG.  151.— Normal  Uterine  Cavity  (Peaslee). 


Fig.  152.— Uterine  Cavity  as  Enlarged  by 
Peaslee's  Operation  (Peaslee). 


lulitis  at  the  Woman's  Hospital,  in  patients  who  had  had  cellulitis  before. 
The  patient  is  kept  in  bed  for  two  or  three  days  and  not  allowed  to  walk 
for  a  week.  The  conical  dilator  of  the  corresponding  size  is  passed  im- 
mediately after  the  removal  of  the  metrotome,  and  every  other  day  for  a 
week,  and  once  a  week  for  two  or  three  weeks  longer. 

Dr.  Peaslee  claimed  to  have  obtained  by  this  operation  a  uterine  canal 
of  the  average  normal  width  in  the  healthy  parous  woman,  as  shown  in 
Figs.  151  and  152. 

The  results  of  this  operation  have  not  been  stated,  any  further  than 
that'  its  author  asserts  that  "  it  removes  stenosis  perfectly,  and  in  most 
cases  permanently,  since  there  is  very  httle  tendency  to  closure  of  the 
slight  incision  made."  If  the  cervical  canal  really  retains  the  width  given 
it  by  Peaslee's  operation,  it  is  evidently  sufficiently  large  for  all  practical 
purposes,  as  regards  the  cure  of  dysmenorrhea  and  sterility,  and  Simpson's 
operation  should  be  abandoned  as  unnecessarily  severe  and  dangerous. 
Sims'  operation,  be  it  understood,  does  not  come  under  this  category, 
being  designed  for  a  different  class  of  cases,  namely,  anteflexion  and  dis- 
tortion of  the  cervix."  

1  It  may  be  well  to  avoid  misunderstanding  by  saying  here  that  Dr.  Peaslee's  idea  of 
the  operation  which  he  called  Sims'  in  his  celebrated  article  on  Incision  and  Discission 


308 


MIXOE    GYNECOLOGICAL    3IANIPULATI0]^S. 


I  am  not  aware  wliether  subsequent  observations  have  proved  the  per- 
manency of  these  superficial  incisions  recommended  by  Dr.  Peaslee.  In 
view  of  the  prevalent  tendency  to  bold  surgical  measiu'es,  his  ad-sice  should 
certainly  be  heeded  and  put  to  the  test. 

Wedge-shaped  Excision  of  the  Lips  of  the  Cervix. — In  some  cases  the 
only  obstruction  to  the  entrance  of  the  seminal  fluid  into  the  uteinis  seems 
to  be  a  peculiar  formation  of  the  hps  of  the  ex- 
ternal OS,  by  which  the  anterior  lip  closes,  as  with 
a  valve  or  ajDron,  the  entrance  to  the  cerdcal  cav- 
ity. Fig.  153  shows  this  fonnation.  To  remove 
this  obstruction  is  obviously  the  indication. 

The  nature  of  the  operation  is  shown  by  the 
dotted  lines  in  the  figmre.  A  straight  sharp-  or 
blunt-pointed  bistoury  is  passed  into  the  external 
OS  and  the  overlapping  anterior  lip  (it  is  seldom 
the  posterior)  is  cut  out  for  about  one-foiu'th  of 
an  inch,  the  piece  removed  having  the  shape  of  a 
short  wedge.  This  little  operation  can  be  per- 
formed at  the  office,  and  is  entirely  devoid  of  dan- 
ger. It  leaves  a  transverse  os  (similar  to  that 
shown  in  Fig.  135),  which  should  be  kept  open  by  first  inserting  a  cotton 
plug  for  several  days,  and  then  occasionally  separating  the  hps  with  a 
branched  dilator,  until  peiTQanent  cicatrization  has  taken  place. 

A  condition  practically  producing  the  same  effect  is  not  unfrequently 
observed  in  parous  women,  in  whom  the  otherwise  large,  perhaps  lacerated, 
external  os  is  almost  completely  closed  by  a  hyperplasia  of  the  follicles  of 
the  lining  membrane  of  the  cervical  canal  on  one  lip  or  the  other.  A 
bright  red,  eroded,  and  easily  bleeding  mass,  resembling  a  strawberry,  is 
seen  occluding  the  os,  and  is  cui'able  by  performing  the  same  wedge- 
shaped  excision.     This  condition  is  represented  in  Fig.  239. 

Other  complicated  excisions  of  the  substance  of  the  cervix  for  the  pur- 
pose of  maintaining  a  patulous  external  os,  have  been  devised  by  Simon, 
Kehrer,  and  others.  Their  consideration  involves  so  much  description, 
and  their  adoption  has  not  as  yet  been  assured,  so  that  I  am  comj)elled  to 
omit  them  from  this  work. 


Fig.  353. — Projection  of  An- 
terior Lip  of  Cervix.  Dotted 
line  marks  incision  for  removal 
of  wedge  (P.  F.  M.). 


VIII.    CURETTING   OF   THE   UTERINE   CAVITY. 

By  curette,  or  scoop,  we  understand  an  instrument  shaped  like  a  spoon, 
which  is  designed  for  the  removal,  by  a  scraping,  tearing,  or  cutting  action, 
of  certain   x^a^^hological   tissues.      The  curette  was   first   introduced  by 


of  the  Cervix  Uteri,  read  before  the  New  York  Academy  of  Medicine,  June  1,  187G, 
aud  published  in  the  American  Journal  of  Obstetrics  for  August,  1876,  has  been  pro- 
nounced erroneous  by  Sims  himself  in  the  paper  above  referred  to  on  Stenosis  Uteri, 
published  in  the  American  Gynecological  Transactions,  Vol.  III.,  1878.  Dr.  Peaslee,  it 
would  seem,  labored  under  a  misapprehension,  and  mistook  a  modified  Simpson  opera- 
tion for  that  which  Sims  wishes  to  be  called  by  his  name,  the  antero-posterior  section. 


CUEETTIISTG    OF    THE    UTERHSTE    CAVITY.  309 

Recamier  in  1846,  and  lias  since  become  exceedingly  popular,  both  in  its 
original  and  various  modified  shapes.  Many  authorities  pronounced  the 
practice  barbarous  and  unscientific  (Chassaignac,  Becquerel,  Dubois,  Scan- 
zoni,  Crede),  but  in  vain  :  the  curette  maintained  its  fame  and  increased 
in  popularity.  And  no  wonder,  for  it  enabled  the  surgeon  to  remove  in 
a  few  moments  with  perfect  certainty,  safety,  and  almost  without  pain, 
pathological  tissue  which  by  caustics  and  acids  could  scarcely  be  removed 
in  weeks.  If  it  was  "  unscientific,"  it  was  effectual,  and  it  certainl}'  is  no 
more  barbarous  to  scraj)e  out  a  cancerous  cervix  or  a  uterus  for  vegeta- 
tions, than  to  cauterize  the  surface  with  fuming  nitric  or  with  chromic 
acid. 

One  or  the  other  form  of  curette  has  therefore  now  become  a  neces- 
sary instrument  to  the  gynecologist.  There  are  four  varieties  of  curettes 
in  present  use  :  the  dull  copper-wire  loo]3,  of  Thomas  ;  the  long  subacute 
spoon,  of  Recamier  ;  the  sliarjD  cutting  loop,  with  flexible  shank,  of  Sims  ; 
and  the  sharp  cutting  spoon,  with  stiff  shank,  of  Simon.  Of  these,  each 
has  its  special  indications  and  dangers,  and  will,  therefore,  be  described 
separately. 

The  Dull  Curette  of  Thomas. 

The  copper-wire  curette,  without  cutting  edge,  was  devised  by  Dr.  T. 
G.  Thomas.  It  is  an  instrument  nine  inches  long,  three  and  one-half  inches 
of  which  form  the  wooden  handle,  made  of  soft  copper  wire,  one-sixth  of 
an  inch  near  the  handle  and  tapering  down  to  one -twelfth  to  one-sixteenth 
of  an  inch  in  thickness  at  one-half  inch  from  the  end,  where  it  is  bent 
into  an  elliptical  loop  one-fourth  of  an  inch  broad,  the  wire  at  the  loop 
being  flattened  on  the  scraping  surface.  The  wire  at  the  incejDtion  of  the 
loop  is  so  soft  and  flexible  that  any  greater  than  a  superficial  pressure 
will  cause  it  to  bend,  whereby  a  deep  injury  to  the  uterine  mucosa  is  abso- 
lutely avoided.  Besides,  at  the  junction  of  wire  and  handle,  the  former  is 
grooved,  so  as  to  bend  easily  at  that  point,  also  with  the  object  of  prevent- 
ing firm  pressui-e.  The  breadth  of  the  loop  mentioned  above,  one-fourth 
of  an  inch,  is  the  usual  size  ;  but  there  are  two  other  sizes  made,  one 
larger  and  one  smaller,  in  proportion  to  the  patency  of  the  cervical  canal. 
I  have  of  late  been  using  for  mere  diagnostic  curetting  a  very  fine,  slender 
loop  devised  by  Bangs  for  exploration  of  the  male  urethra. 

It  may  seem  that  this  flexible  blunt  loop  of  wire  is  too  frail  to  be  of 
real  service,  but  experience  has  amply  shown  that  it  fully  answers  the  pur- 
pose for  which  it  was  intended,  and  that  gently  drawing  it  over  the 
uterine  mucous  membrane  suffices  to  detach  the  projecting  vegetations  or 
granulations  and  to  cure  the  case,  without  requiring  or  subjecting  the 
patient  to  the  danger  accompanying  the  use  of  a  stiff,  sharp  steel  scoop. 

Indications. — There  is  really  only  one  indication  for  the  use  of  the 
curette,  and  that  is  pathological  uterine  hemorrhage,  menorrhagia,  or 
metrorrhagia,  which  has  resisted  all  other  remedies,  and  for  which  no 
physical  cause,  constitutional  or  local,  can  be  detected  by  the  usual  means 


310  MIN-OR    GYNECOLOGICAL    MANIPULATIONS. 

of  exploration.  In  such  a  case  Ave  are  compelled  to  look  for  the  cause  of 
the  hemorrhage  in  some  intra-uterine  disease,  not  distinguishable  by  the 
ordinary  digital  and  specular  examination.  The  curette  Avill  then  give  us 
the  required  information,  for  by  it  we  shall  either  remove  a  portion  of  the 
growths  causing  the  hemorrhage,  or  receive  a  negative  result  at  least,  in 
the  assurance  that  the  uterine  cavity  is  empty  and  healthy.  The  first  and 
chief  use  of  the  curette,  therefore,  is  as  a  means  of  diagnosis,  and  as  such 
it  must  be  employed  in  almost  every  case  until  its  withdrawal  shows  the 
presence  or  absence  of  an  exciting  cause.  The  unirritating  nature  of  the 
operation  with  the  wire  curette  renders  this  procedure  entirely  justifiable 


Fig.  154. — Thomas'  Dull  Copper-wire  Curette. 

and  harmless,  while  sufficiently  effective.  Having  thus  ascertained,  by 
means  of  the  curette,  what  the  cause  of  the  hemoiThage  is,  if  located  in  the 
uterus,  we  find  that  it  is  one  of  three  conditions  requiring  the  therajjeutio 
employment  of  the  curette.  These  are,  taking  them  in  the  order  in  which 
they  are  commonly  met  with  :  1.  Chronic  hyperplastic  endometritis,  or 
fungous  degeneration  of  the  uterine  mucous  membrane.  2.  Retention  of 
adherent  placental  villi  after  miscarriage.  3.  Diffuse  sarcoma  of  the  mu- 
cosa of  the  body  of  the  uterus. 

1.  Endometritis  hyperplastica  chronica  or  polyposa  (Olshausen),  fun- 
gous degeneration  of  the  uterine  mucous  membrane  (Thomas),  fongosites 
uterines  (Eecamier),  endometritis  chronica  (Hegar  and  Kaltenbach),  me- 
tritis hemorrhagica  (Weber,  St.  Petersburg),  metritis  villosa  (Slavjansky), 
manifests  itself  by  three  separate  anatomical  conditions  :  (a)  diffuse,  low 
granulations,  developed  in  patches,  eroded  and  ulcerated  by  chronic  catarrh, 
or  spread  over  the  whole  mucosa,  similar  to  gxanular  conjunctivitis  (Att- 
hill) ;  (6)  a  uniform  general  hyperplasia  of  the  whole  mucosa  of  the  uterine 
body  without  polypoid  formations,  "  an  unhealthy  pulpy  condition  of  the 


Fig.  155. — Thomas'  Curette,  Medium  Size. 

mucous  coat "  (Tanner) ;  and  (c)  numerous  polypoid  fungous  vegetations 
scattered  over  the  hyperplastic  mucosa,  the  endometritis  polyposa  of 
Olshausen.  In  this  last  category  might  be  included  mucous  polypi,  which, 
however,  are  rare  in  the  cavity  of  the  uterus  projDer,  and  are  generally 
confined  to  a  limited  portion  of  the  endometrium. 

All  these  pathological  conditions  are  well  known  to  produce  hemor- 
rhage, which  is  arrested  only  by  the  removal  of  the  exciting  cause.  The 
masses  removed  by  the  wire  curette  in  class  a  will  generally  possess  more 
the  character  of  fine  shreds  and  tui'bid  bloody  mucus  without  actual  dis- 
tinct pieces  of  tissue,  the  curette  merely  crushing  and  obhterating  the 


CUKETTINGT    OF   THE    UTERINE    CAVITY.  311 

flabby  granulatioBS ;  in  class  b,  soft  pale  slices  and  irregular  patches  will 
come  away  ;  and  in  class  c,  distinct,  flattened,  polypoid  vegetations,  vary- 
ing in  size  from  a  millet-seed  (the  usual  size)  to  a  pea  or  bean,  and  soft 
and  pulpy  in  consistence. 

Occasionally  all  these  neoplasms  are  combined,  and  removed  in  the 
same  case. 

The  vegetations,  or  fungosities  consist  histologically  of  structureless 
basement  substance,  containing  great  quantities  of  small  round-cells  and 
nuclei,  and  j)ortions  of  uterine  follicles  and  vessels.  Granulations  have  no 
follicles. 

Olshausen  states  that  endometritis  polyposa  strongly  resembles  the 
broad  based  molluscum  of  the  corpus  uteri  described  by  Virchow,  the 
great  difference  being,  however,  that  in  the  latter  affection  large  masses 
of  dilated  glands  are  found,  which  are  absent  in  the  formei-.  A  micro- 
scopical examination  will  usually  be  required  to  determine  the  exact 
nature  of  the  masses  removed,  should  there  be  any  doubt  on  the  matter. 
It  should  further  be  stated,  that  endometritis  polyposa  is  limited  strictly  to 
the  cavity  of  the  uterus  proper,  stopping  at  the  os  internum,  below  which 
commences  the  region  of  enlarged  Nabothian  follicles  and  mucous  polypi, 
for  the  removal  of  which  Thomas  himself  recommends  Sims'  sharjD  curette. 

Endometritis  polyposa  is  not  confined  to  the  married  or  parous 
woman,  but  occurs  also  not  unfrequently  in  the  single  female,  even  after 
the  menopause.  It  generally  owes  its  origin  to  a  chronic  catarrh  of  the 
endometrium,  the  ordinary  muco-purulent  discharge  of  which  has  grad- 
ually become  more  sanious  or  pure  bloody,  accompanied  by  jDrofuse  men- 
strual flow,  and  gradually  increasing  anemia,  and  general  debihty.  The  ■ 
previous  existence  of  a  profuse  chronic  leucorrhea  will,  therefore,  convey  a 
suspicion  of  the  presence  of  this  affection.  The  local  symptoms  are  often 
slight,  generally  merely  the  ordinary  pelvic  weight  and  dragging  met  with 
so  commonly  in  uterine  disease.  The  cervix  is  usually  soft,  the  external 
OS  often  more  or  less  gaping,  and  the  cervical  canal  and  internal  os  patu- 
lous. The  finger  passed  into  the  uterine  cavity  will  feel  the  mucous  mem- 
brane swollen  and  spongy.  To  detect  the  vegetations  themselves  by  the 
touch  would  scarcely  be  possible,  owing  to  their  scattered  site,  small  size, 
and  pulpy  consistency.  No  one  portion  of  the  endometrium  seems  par- 
ticularly favored  by  these  gi-owths,  for  I  have  removed  them  vrith  the 
curette  from  either  surface.  The  number  of  vegetations  may  vary  from 
two  or  three  to  a  dozen,  or  a  whole  teaspoonful  or  more,  their  size  from  a 
millet-seed  to  a  beau,  the  latter  being  rarely  met  with. 

I  have,  in  a  certain  number  of  cases,  found  the  presence  of  metror- 
rhagia due  to  vegetations  accompanied  by  a  marked  laceration  of  the 
cervix.  Unquestionably,  this  laceration  was  the  first  factor  in  the  chain  of 
pathological  changes,  viz.,  laceration,  subinvolution,  hyperplasia  of  stroma 
and  mucous  membrane  of  uterus,  proliferation  of  glandular  elements,  vege- 
tations, hemorrhage.  The  treatment  must,  therefore,  proceed  in  the  in- 
verse ratio  :  removal  of  vegetations,  reduction  of  enlargement  of  mucosa 
and  stroma  of  uterus ;  finally,  for  permanent  cure,  union  of  laceration. 


312  MI]S"OE    GYIVTECOLOGICAL   MA:N-IPULATI0KS. 

When  we  consider  liow  easily  the  diagnosis  of  this  affection  is  now 
made  by  the  curette,  we  must  wonder  at  its  having  been  so  rarely  recog- 
nized, and  so  little  appreciated,  as  it  undoubtedly  has  been  since  its  dis- 
covery some  thirty  years  ago.  The  explanation  given  by  Olshausen  for 
this  neglect  is  probably  the  correct  one,  namely,  that  the  sharp  curette 
having  been  proscribed,  the  only  means  of  diagnosis  of  the  affection  was 
by  the  finger,  after  opening  the  canal  by  laminaria  or  sponge-tent  (still  the 
only  method  advised  by  Atthill,  in  1873),  the  former  of  which  flattened  out 
the  growths  and  rendered  them  impalpable,  and  the  removal  of  the  latter 
destroyed  them. 

After  what  has  been  already  said,  it  seems  scarcely  necessaiy  to  remark 
that  constitutional  treatment  is  of  no  avail  whatever  for  the  cure  of  this 
affection,  and  consists  only  in  remedies  designed  to  support  and  restore 
strength.  Topical  applications  of  caustics  (argenti  nitras,  tincture  of 
iodine,  liq.  ferri  persulph.,)  have  by  long  experience  been  found  but  tem- 
porarily beneficial  in  arresting  the  hemorrhage  ;  stronger  caustics,  such  as 
nitric  and  chromic  acid,  will,  it  is  true,  convert  the  whole  surface  of  the 
uterine  mucosa  into  an  eschar,  and  thus  probably  cure  the  disease.  But 
as,  in  any  case,  the  disease,  with  its  exciting  cause,  is  liable  to  recur,  and 
as  the  use  of  these  strong  caustics  is  always  attended  with  more  incon- 
venience, pain,  and  danger  than  are  ever  found  to  result  from  the  simple 
operation  mth  the  wire  curette,  the  latter  instrument  should  invariably  be 
preferred  to  caustics  in  these  cases. 

2.  Placental  villosities  are  very  frequently  detected  in  utero  after  a  mis- 
carriage, particularly  when  the  placenta  was  expelled  alone,  after  the  birth 
of  the  embryo,  or  was  manually  removed.  These  patients  generally  con- 
tinue flowing  after  the  miscarriage  for  a  longer  or  shorter  time  (often  pro- 
fusely), until  their  weakened  state  finally  obliges  them  to  seek  medical 
advice,  usually  after  the  fruitless  employment  of  a  variety  of  constitutional 
hemostatics.  Shoiold  the  cervical  canal  still  be  sufiiciently  patent,  the 
finger  will  readily  detect  an  irregular,  rough,  circumscribed  spot  on  the 
endometrium.  Or  what  is  equally  positive  and  more  aj)plicable  through 
the  generally  contracted  os,  the  curette  makes  that  discovery,  and  at  once 
removes  a  fragment,  the  macro-  and  microscopical  appearance  of  which 
readily  assures  the  diagnosis,  and  points  out  the  immediate  cure  of  the 
hemorrhage,  by  the  removal  of  its  exciting  cause. 

3.  Diffuse  sarcoma  of  the  uterine  coi-poreal  mucosa  is  a  very  rare  dis- 
ease, only  sixteen  instances  of  which  have,  according  to  Schroeder,  been 
recorded  in  literature.  It  should  not  be  confounded  with  sarcoma  of  the 
parenchyma  of  the  uterus,  which  is  decidedly  more  frequent,  and  resem- 
bles, in  its  macroscopical  characteristics,  the  ordinary  fibroid  tumor  of  the 
uterus.  Diffuse  sarcoma  of  the  mucous  membrane  is  confined  almost  ex- 
clusively to  the  body  of  the  uterus,  only  two  cases  of  its  occurrence  in  the 
cervix  being  recorded  (both  by  Spiegelberg),  and  appears  as  a  soft,  flabby, 
villous  growth,  spreading  over  a  greater  or  lesser  surface,  and  rapidly  as- 
suming an  irregular  polypoid  shape.  It  is  in  its  early  stages  only,  that  it 
is  amenable  to  treatment  by  so  simple  an  instrument  as  the  wire  curette  ; 


CUEETTING    OF    THE    UTERINE    CAVITY.  313 

later  on  the  sharp  scooj)  or  the  galvano-cautery  are  requh-ed.  The  differen- 
tial diagnosis  between  diffuse  sai'coma,  unusually  prolific  vegetations,  and 
retained  placental  fragments,  can,  as  a  rule,  be  made  with  certainty  only 
by  the  microscope,  and  is  then  easy  enough,  the  distinctive  histological 
features  of  each  of  these  masses  being  sufficiently  characteristic.  The 
symptoms  of  diffuse  sarcoma  in  the  early  stages  resemble  those  of  endo- 
metritis polyposa,  but  the  hemorrhage  is  generally  more  profuse,  and  al- 
ternates with  watery  discharges  frequently  mixed  with  shreds,  and  there 
is  often  more  or  less  pelvic  pain. 

Another  class  of  cases  in  which  the  wire  curette  can  be  advantageously 
and  safely  used,  are  those  of  carcinoma  of  the  cervix,  in  which,  after  ampu- 
tation, the  sharp  scoop  or  cautexization,  fresh,  readily-bleeding  granulations 
spring  up.  These  I  have  repeatedly  removed  off-hand  with  Thomas'  cu- 
rette, applied  nitric  or  chromic  acid,  or  bromine,  or  solution  of  the  per- 
sulphate of  iron,  and  sent  the  patient  home.  Large  masses  of  cancerous 
tissue  would,  however,  require  a  more  powerful  instrument,  like  Simon's 
sharp  scoop,  the  use  of  which  should  be  attended  by  all  the  precautions 
employed  during  and  after  a  serious  operation. 

While  for  mere  diagnostic  curetting  it  is  not,  as  a  rule,  necessary  to 
anesthetize  the  patient,  the  thorough  scraping  of  the  uterine  cavity  is  de- 
cidedly faciHtated  by  rendering  the  patient  insensible  to  pain.  Formerly, 
I  did  not  think  this  necessary,  and  have  curetted  many  a  uterus  at  my  of- 
fice and  the  dispensary,  allowing  the  woman  to  return  home  immediately 
afterward,  with  dii-ections  to  keep  quiet  for  a  day  or  two,  and  no  bad  re- 
sults followed  this,  which,  in  later  years,  I  have  recognized  to  be  a  hazard- 
ous practice.  One  or  two  experiences  of  quite  profuse  hemorrhage  during 
the  curetting,  and  three  cases  of  cellulitis  following  curetting  and  cauteri- 
zation with  nitric  acid  of  the  cervical  cavity  only,  have  rendered  me  more 
cautious  in  these  apparently  trifling  operations ;  and  I  now  7iever  do  thor- 
ough therapeutic  curetting  elsewhere  than  at  the  residence  of  the  patient, 
keeping  her  in  bed  for  three  or  four  days  afterward,  and,  unless  the  pa- 
tient objects  or  a  counter-indication  exists,  I  prefer  to  use  an  anesthetic. 

It  is  doubtless  possible  to  introduce  the  curette  into  the  uterus,  and 
scrape  over  more  or  less  of  its  cavity  through  a  bivalve  or  cylindrical  specu- 
lum, or  without  a  speculum,  on  the  finger  only  ;  but  svich  a  procedure  can 
be  at  best  incomplete  (then  truly  performed  "  almost  at  random,"  as  Att- 
hill  says),  because  the  narrow  field  afforded  by  the  specula  named  jDre- 
vents  free  movement  of  the  instrument.  An  inflexible  steel  curette  can 
doubtless  accomplish  its  purpose  when  simply  introduced  on  the  finger, 
and  I  have  repeatedly  removed  both  carcinomatous  masses  and  large 
masses  of  j)lacenta  in  this  manner  with  Simon's  scoop,  guarding  uterus 
and  instrument  with  the  other  hand  on  the  abdomen.  But  the  only  true 
way  of  operating  with  Thomas'  curette,  is  through  Sims'  speculum  in  the 
left  semiproue  position. 

The  patient  having  been  placed  in  Sims'  position,  and  the  cervix  being 
exposed  with  Sims'  speculum,  the  operator  seizes  the  anterior  lip  of  the 
cervix  with  a  tenaculum,  da'aws  the  uterus  gently  down,  thereby  straight- 


314  MII^OE    GYNECOLOGICAL    MANIPULATIONS. 

ening  its  canal  and  holding  it  steady,  introduces  tlie  sound  or  probe  to 
ascertain  the  dii'ection  and  length  of  the  uterine  canal.  Bending  the 
shank  of  the  curette,  in  accordance  with  the  information  thus  obtained,  he 
passes  it  into  the  cavity  of  the  uterus,  which  he  carefully  explores  by 
drawing  the  curette  gently  over  the  whole  mucous  membrane,  always  in 
the  du'ectiou  from  the  fundus  to  the  internal  os.  Should  the  vegetations 
be  large  or  very  numerous,  or  the  mucosa  much  hypertroj)hied,  a  certaia 
feehug  of  resistance  or  a  rough  grating  sensation  wiU  be  imparted  to  the 
finger  of  the  operator,  reveahng  to  him  the  presence  of  the  neoplasms. 
In  case  of  adherent  placental  remnants,  this  gi'ating  sensation  is  particu- 
larly distinct,  and  can  even  be  faintly  audible  to  the  bystander.  A  very 
shght  flow  of  blood  accompanies  this  operation,  never  more  than  a  table- 
spoonful  or  two.  Having  completed  the  tour  of  the  uterine  cavity  the 
curette  is  withdrawn,  bringing  with  it  blood,  and,  if  present,  vegetations, 
placental  fragments,  or  carcinomatous  masses.  These  are  easily  secured 
and  detected  by  wijDing  out  the  vagina  with  dry  cotton,  on  which  the 
small,  pale,  flat,  elongated,  homogeneous-looking  vegetations,  or  the  firmer 
pai'ticolored  jDlacental  fragments,  are  readily  discernible  amid  the  coagula. 
The  detection  of  sarcoma  will  devolve  on  the  microscope.  If  the  operator 
wishes  to  make  sure  that  all  neoplastic  formations  have  been  removed,  the 
curette  may  again  be  inti-oduced,  and  the  vagina  then  tamponed  with  cot- 
ton soaked  in  glycerine.  In  severe  cases  a  dose  of  moi-phine  may  be  or- 
dered after  the  operation,  and  I  generally  leave  a  prescription  for  mor- 
phine suppositories  to  be  used  if  required  ;  but  often  no  other  immediate 
after-treatment  than  rest  is  required.  I  have  been  in  the  habit  of  painting 
the  whole  of  the  uterine  cavity,  immediately  after  cleansing  it  with  cotton, 
with  Churchill's  tincture  of  iodine,  as  a  styptic  and  caustic  (although  really 
not  needed  as  such),  and  chiefly  as  a  disinfectant  and  alterative,  to  insure 
the  thorough  destruction  of  the  neoplasms  and  the  absorption  of  the  hy- 
perplastic tissue ;  in  protracted  cases,  where  the  number  of  vegetations 
was  great  or  the  hemorrhage  profuse,  I  have  left  a  tent  of  cotton  soaked  in 
iodine  in  the  uterine  cavity,  directing  the  patient  to  Avithdraw  it  by  the 
attached  string  in  forty-eight  hours,  when  she  removes  the  vaginal  tam- 
pons. If  the  uterine  plug  should  resist  traction,  it  may  be  left  in  another 
twenty-four  hours.  In  order  to  enable  the  patient  to  distinguish  the 
string  of  the  uterine  plug  from  those  of  the  vaginal  tampons,  it  is  well  to 
make  a  knot  in  it.  I  have  never  seen  the  least  ill-effects  from  this  treat- 
ment, but  do  not  deny  that  I  may  be  mistaken  in  considering  it  more 
efficacious  than  the  simple  painting  of  the  cavity. 

Should  the  neoplasm  be  discovered  to  be  sarcoma,  the  cavity  of  the 
uterus  must  be  thoroughly  opened  by  laminaria  or  tupelo,  and  nitric  acid 
or  the  galvano-cautery  apphed. 

As  a  rule  the  external  os  is,  even  in  nulliparae,  sufficiently  patent  to 
admit  the  curette,  and  the  same  may  be  said  of  the  internal  os,  which  the 
profuse  hemorrhage  has  tended  to  dilate.  Occasionally,  when  even  the 
smaller-sized  curette  will  not  pass,  I  dilate  the  internal  os  with  EUinger's 
steel  two-branched  dilator,  and  then  experience  no  further  difficulty.     Di- 


CURETTING    OF    THE    UTERINE    CAVITY.  315 

latation  with  tents  is  rarely  required.  The  pain  attending  the  operation 
of  curetting,  as  above  described,  is  usually  but  slight ;  it  occupies  barely 
five  minutes,  and  the  reaction  is  nil.  As  I  have  already  stated,  it  is  advis- 
able to  avoid  all  risks  by  performing  the  operation  at  the  house  of  the  pa- 
tient or  in  a  hospital,  and  keeping  her  in  bed  for  twenty-four  hours  after- 
ward. The  simple  introduction  of  the  sound  has  produced  cellulitis  and 
metroperitonitis  ;  it  cannot  be  denied,  therefore,  that  the  wire  curette  may 
at  any  time,  in  a  peculiarly  susceptible  patient,  Ught  up  a  similar  trouble. 


^^^^^^^^^J 


Pig.  156. — Mnnde's  Large  Dull  Curette  for  Removal  of  Placenta  after  Abortion,  Natural  Size. — Length  of 
whole  instrument,  with  handle,  sixteen  inche.s.  Used  chiefly  to  pry  and  scrape  away  the  placenta,  in  a 
longitudinal  direction  (P.  F.  M.). 

But  an  ordinary  diagnostic  exploration  of  the  uterus  with  the  curette,  and 
the  gentle  removal  of  a  few  vegetations,  is  really  an  almost  innocuous  pro- 
cedure, and  not  likely  to  be  followed  by  evil  consequences,  even  if  per- 
formed in  the  physician's  office. 

It  must  be  boi'ne  in  mind  that,  if  the  diagnostic  curetting  does  not  de- 
tect any  cause  of  the  hemorrhage,  at  all  events  no  harm  has  been  done, 
and  the  negative  answer  is  in  itself  valuable  information.  Cases  are  even 
met  with  in  which  the  curetting,  while  not  detecting  any  neoplasm,  still 
cures  the  metrorrhagia  apparently  by  its  alterative  stimulant  action  on  the 
relaxed  uterine  mucous  membrane.  And  this  is  doubtless  the  manner  in 
which  it  benefits  cases  of  granulation  and  diffused  tumefaction  of  the  en- 
dometrium without  vegetations. 

If  the  uterine  mucous  membrane  is  healthy  the  wire  curette  will  not 
injure  it,  and  no  shreds  will  therefore  be  removed  ;  with  the  sharp  curette, 
however,  even  the  most  delicate  and  practised  hand  can  scarcely  avoid 


Fig.  IST. — Elliptical  Loop  to  be  Screwed  on  Handle  of  Munde's  Placental  Curette. — Chiefly  used  for 
smaller  os,  and  lateral  motion  in  sci-apiiig  (P.  F.  M.). 

shaving  off  slices  here  and  there,  the  depth  of  which  lesions  cannot  always 
be  foreseen.  It  is  this  latter  diagnostic  curetting  which  must  be  termed 
harsh  and  "unscientific." 

Counter-indications  do  not  really  exist,  except  such  as  would  equally 
prohibit  the  introduction  of  the  sound,  viz.  :  acute  or  moderately  recent 
pelvic  or  uterine  inflammation,  which  should  first  be  allayed  by  appropriate 
means  before  hazarding  the  curette. 

I  have  employed  the  dull  curette  many  times,  and  have  never  failed  to 


816  MII^OR    GYNECOLOGICAL    MANIPULATIONS. 

cure  tlie  case  when  tlie  diagnostic  cui-etting  showed  the  presence  of  any  of 
the  benign  neoplasms  described  above.  In  certain  cases  of  hyperplastic  or 
subinvoluted  uterus,  with  large  cavity  and  gaping  orifice,  a  larger  sized  cu- 
rette (Fig.  155),  which  occuj)ies  about  the  middle  place  between  the  small 
scoop  shown  in  Fig.  154  and  the  largest  size  seen  in  Fig.  156,  will  enable 
us  to  remove,  with  far  more  certainty,  every  vestige  of  pathological  tissue, 
which  might  here  and  there  escape  the  smaller  instrument.  The  large 
curette  seen  in  Fig.  156  is  used  solely  to  remove  the  whole  j)lacenta  or  por- 
tions of  it  immediately  or  within  several  days  after  abortion,  so  long  as 
the  cervical  canal  is  still  sufficiently  open  to  admit  it.  It  is  not  used  with 
a  scraping  motion  when  the  whole  placenta  is  to  be  removed,  but  pries  the 
organ  off  from  the  uterine  waU  by  gentle  oscillatory  movements,  until  the 
whole  is  detached,  when  it  is  removed  by  long  broad-bladed  forceps.  If 
only  small  lobes  of  placenta  or  diffuse  viUosities  are  to  be  removed,  the 
usual  scraping  action  is  emjDloyed. 

Recamier''s  Curette. 

The  subacute  curette  {Recamier's)  is  represented  in  the  cut.  It  is  used 
very  much  in  the  same  manner  as  the  dull  scoop,  except  that  the  scraping 
action  is  exercised  from  side  to  side,  and  not  from  above  downward.  The 
peculiar  shape  of  the  instrument  and  lateral  situation  of  its  subacute  edge 
accounts  for  this. 


Fig.  158. — R6camier's  Subacute   Curette. 

The  indications  are  precisely  the  same  as  those  for  the  duU  curette, 
and  need  not  therefore  be  repeated.  I  decidedly  prefer  the  former  instru- 
ment, as  more  safe  while  quite  as  efficient.  Recamier  himself  met  with 
three  cases  of  death  from  perforation  of  the  uterus  by  his  curette  ;  Demar- 
quay  with  two  ;  Chamberlain,  of  New  York,  saw  a  case  of  hysterical  te- 
tanus therefrom  ;  Peaslee  a  death  from  collapse  ;  Thomas  a  narrow  escape 
from  the  same  cause,  and  Barker  a  case  of  peritonitis. 

Nevertheless,  it  is  stiU  kept  in  the  shops  and  used  by  many  operators. 

Emmet  has  devised  a  curette-forceps,  which  resembles  a  double  Ee- 
camier's  curette.  With  it  he  crushes  and  removes  the  uterine  vegetations, 
as  he  claims,  quite  as  effectually  as  can  be  done  by  the  ordinary  curette. 

Sims'  Sharp  Curette. 

The  sharp  curette  with  flexible  shank  (Sims')  consists  of  a  steel  loop  with 
sharp,  cutting  edge,  and  with  a  steel  shank  sufficiently  flexible  to  permit 
its  being  bent  in  any  case  to  suit  the  uterine  canal,  and  to  prevent  too 
much  force  being  exerted  during  the  operation.  It  may  be  made  of 
several  sizes,  the  one  usually  employed  being  the  smaller  instrument  in 
the  cut. 


CURETTING    OF    THE    UTERINE    CAVITY. 


Sir 


Indications. — Whenever  a  dull  curette  can  be  employed,  tliere  also  may 
a  sliarj)  scoop  be  used,  if  the  operator  feels  sufficiently  skilful  to  avoid 
doing  injury.  But,  as  already  stated,  what  can  be  done  by  a  safe,  and 
•withal  efficient  instrument,  should  not  be  joerformed  by  another  possessed 
of  more  dangerous  qualities.  Therefore,  all  ordinary  benign  vegetations 
and  hyperplastic  conditions  of  the  endometrium  should  be  treated  by  the 
dull  curette  ;  and  only  when  these  vegetations  acquire  the  suspicion  of 
malignancy  by  their  repeated  return,  or  their  microscopic  appearance  re- 
veals the  j^resence  of  heterogeneous  tissue,  or  the  scrapings  are  of  undoubted 
malignant  character,  is  it  indicated  to  remove  them  and  their  substratum 
by  a  more  powerful  instrument.  The  sharp  curette  then  comes  into  play 
within  the  uterine  cavity.  It  should,  of  course,  be  handled  carefully,  in 
order  not  to  cut  too  deeply  and  perhaps  perforate  the  uterine  wall,  as  hap- 
j)ened  to  Spiegelberg  and  to  Chrobak  while  cui-etting  a  sarcoma  of  the  uter- 
ine cavity.  Only  unjustifiable  brutal  force  could  possibly  j)erforate  a  nor- 
mal uterine  wall  with  Sims'  curette. 


Fig.  159.— Sims'  Sharp  Curette,  vnth  Flexible  Shanlc. 

Where  it  is  desired,  therefore,  to  remove  all  pathological  tissue  thor- 
oughhj,  even  down  to  the  muscular  coat,  the  sharp  curette  should  be  em- 
j)loyed. 

Another  special  indication  for  Sims'  curette  is  a  chronic,  intractable 
endotrachelitis  dej)ending  on  hypei-plasia  of  the  cervical  glands  and  asso- 
ciated with  redundancy  of  the  interglandular  structure  of  the  cervical  mu- 
cous membrane.  Mild  apphcations,  even  strong  acids,  fail  to  destroy  the 
redundant  tissue,  and  only  its  complete  removal  will  cure  the  case.  This 
is  easily,  safely,  and  almost  painlessly  done  by  the  sharp  curette.  The  dull 
curette  is  not  sharp  enough  and  too  flexible  to  scrape  away  the  dense  tis- 
sue, which  may  even  need  tlie  inflexible  scoop  of  Simon. 

The  sharj)  curette  is  used  through  the  Sims  speculum  precisely  like  the 
wire  loop.  Of  course  the  cervix  must  be  sufficiently  dilated  to  permit  its 
easy  passage  and  handling.  The  swabbing  of  the  uterine  cavity  with  tinct- 
ure of  iodine,  iodized  phenol,  even  nitric  acid  is  indicated  more  after  the 
sharp  than  the  dull  curette,  in  accordance  with  the  gi'avity  of  the  disease 
calling  for  the  oi^eration.  In  the  cervical  cavity  the  above  caustics  are 
usually  applied  after  the  curetting.  If  the  external  os  is  too  small  to  ad- 
mit the  curette,  it  must  be  dilated  or  incised,  as  already  described. 

I  have  had  made  a  sharp  steel  curette,  with  slightly  flexible  shank, 
■which  in  shape  and  size  closely  resembles  the  dull  wii'e  loop  of  Thomas. 


318  MINOR    GYNECOLOGICAL    MANIPULATIONS. 

Its  flat  surface,  while  rendering  it  thoroughly  efficient  on  a  level  plane, 
prevents  the  possibility  of  removing  (gouging  out)  deeper  tissues,  as  may 
so  readily  occur  with  the  more  curved  instrument  of  Sims. 


Simon's  Sharp  Curette. 

The  sharp  curette  with  inflexible  shank  (Simon's)  was  devised  by  the  late 
Prof.  Simon  in  1872,  for  the  removal  of  cancerous  tissue  from  the  cervix 
uteri,  in  incurable  cases,  and  for  scraping  out  old  lymphatic-gland  ab- 
scesses and  carious  bones. 

The  instrument  is  composed  of  stiff,  inflexible  steel,  the  edge  of  the 
scoop  being  decidedly  sharp,  and  the  spoon  itself  quite  deep  and  not  per- 
forated. There  are  five  sizes,  varying  from  that  of  a  lentil  to  a  small  almond, 
with  different  curves  of  the  stems  to  correspond  to  the  various  parts  of  the 
uterine  cavity.  The  steel  stems  are  fixed  in  stout  wooden  handles,  the 
whole  being  of  sufficient  length  (ten  inches)  to  permit  of  their  being 
passed  into  the  uterine  cavity  without  the  aid  of  the  speculum. 


Fig.  160.— Simon's  Sharp  Curette,  with  StifE  Shank. 

The  indication  for  these  stiff  scoops  is  the  removal  of  soft,  fungous, 
bleeding  granulations  in  cancer  of  the  cervix,  which  has  spread  so  far  into 
the  parametrium  as  to  render  the  complete  removal  of  the  diseased  tissue 
impossible.  These  granulations  bleed  and  discharge  freely,  and  thereby 
greatly  debilitate  the  patient.  Active  caustics  do  not  destroy  the  bleed- 
ing masses  thoroughly,  and  besides  are  not  quite  safe  owing  to  the  prox- 
imity of  the  bladdei',  rectum,  and  peritoneum.  In  the  curette  we  possess 
an  instrument  which  enables  us  to  remove  these  bleeding,  cancerous 
masses  rapidly,  safely,  and  effectually.  With  the  larger  sizes  the  whole 
surface  is  quickly  scraped  clean,  and  with  the  smaller  scoops  the  crevices 
and  cavities  in  the  cervix  are  gouged  out  and  all  cancerous  tissue  removed 
from  them.  In  this  manner  the  hemorrhage  and  discharge  is  at  once 
checked,  and  the  patient  allowed  to  recuperate  and  regain  comparative 
health,  until  after  a  few  weeks  or  months  the  granulations  sprout  out 
again,  and  the  operation  has  to  be  repeated  again  and  again,  until  finally 
the  patient  succumbs  to  the  constitutional  effects  of  the  disease.  But  her 
life  has  been  prolonged  by  the  curettings,  and  this  is  all  that  could  be 
expected.  I  have  repeatedly  seen  the  raw,  scraped  surface  cicatrize  over 
and  the  hemorrhage  cease  entirely,  the  neoplasm  continuing  to  grow  into 
the  parametrium  and  finally  killing  by  cachexia. 

It  is,  however,  not  advisable  to  curette  every  case  of  cancer  of  the  cer- 
vix in  which  there  may  be  malignant  granulations  at  the  external  os.  If 
they  do  not  bleed,  let  them  alone,  for  in  su.ch  cases  I  believe  that  too  early 
interference  seems  to  stimulate  the  neoplasm  to  more  rapid  growth.     You 


CUKETTING    OF    THE    UTERINE    CAVITY.  319 

cannot  ciire  the  patient  in  any  case  ;  therefore  do  not  operate  on  her  un- 
less there  is  a  decided  indication  and  a  reason  for  haste. 

Occasionally,  it  may  be  necessary  to  remove  more  than  the  superficial 
cancerous  granulations  from  a  funnel-shaped  cervix  with  the  curette.  A 
whole  enlarged  epitheliomatous  cervix,  a  cauliflower  growth,  may  need  to 
be  rapidly  removed,  and  no  other  instrument  is  at  hand,  or  the  galvanic 
cautery  battery  does  not  work  (each  of  which  occurrences  happened  to  me 
once)  ;  in  the  largest  sharp  curette  we  then  have  a  very  efficient  instru- 
ment for  the  removal  of  even  so  large  a  cervix.  The  epitheliomatous  pro- 
liferations are  soft  and  spongy,  and  readily  yield  to  determined  and 
vigorous  strokes  with  the  instrument. 

The  sharp  curette  has  also  been  used  to  remove  the  whole  or  remnants 
of  placenta  from  the  uterine  cavity  after  abortion.  Boeters,  of  Berlin,  has 
thus  recommended  and  employed  it,  and  I  myself  did  so  in  two  cases  be- 
fore Boeters.  But  this  was  before  I  had  the  large  dull  curette,  which  I 
should  unhesitatingly  prefer. 

Method  of  using  Simon's  Curette. — The  cui'ette  may  be  used  under 
guidance  of  the  finger  only,  or  what  is  better,  through  a  Sims  or  Simon 
speculum,  which  enables  us  to  apply  a  caustic  or  tampon  after  the  opera- 
tion is  completed.  The  larger  spoons  are  first  used  to  remove  all  loose 
superficial  tissue,  and  when  the  surface  is  smooth  the  smaller  sizes  are 
employed  to  scrape  out  the  various  crevices  in  the  growth,  and  to  clear  the 
cervical  canal  as  high  as  the  internal  os,  or  higher  if  the  disease  has  spread 
so  far.  The  scraping  is  done  with  some  force,  and  we  can  tell  when  the 
fibrous  substratum  has  been  reached  by  the  hard,  grating  feel  conveyed 
through  the  instrument.  The  soft,  cellular,  cancer  masses  are  easily  re- 
moved and  gouged  out,  sometimes  leaving  quite  a  socket  behind  them. 

The  hemorrhage  during  the  operation  is  ordinarily  slight,  although  for 
the  moment  it  may  appear  profuse,  and  ceases  as  soon  as  the  vagina  is 
mopj)ed  out.  The  curette,  in  fact,  arrests  the  hemorrhage  by  removing 
its  source,  the  vascular  granulations.  The  point  is  to  operate  rapidly, 
vigorously,  and  thoroughly,  and  but  little  blood  will  be  lost.  Simon 
used  only  cold-water  injections  after  the  operation,  but  I  have  been  in 
the  habit  of  applying  either  an  astringent,  like  saturated  solution  of  alum 
or  resin  in  alcohol,  or  more  generally  a  caustic  to  the  raw  surface.  I  pre- 
fer the  chloride  of  zinc,  one  to  five,  or  stronger  if  a  more  decided  slough 
is  desired,  cotton  pledgets  being  soaked  in  the  solution,  squeezed  dry,  and 
placed  in  the  excavated  cavity,  to  be  left  there  for  three  or  four  days  until 
they  come  away  voluntarily.  The  saturated  solution  of  chromic  acid,  or 
persulphate  of  iron  and  glycerine,  may  also  be  used.  The  details  of  these 
applications  have  already  been  desci'ibed  in  the  chapter  on  ApiDlications  to 
the  Cervix.  It  is  obvious  that  the  escharotic  effect  of  these  agents  Avill  be 
more  thorough  now  than  before  the  cm-etting. 

The  pain  attending  this  operation  is  generally  not  very  great,  but  it  is 
better  to  give  an  anesthetic,  since  a  sensitive  patient  might  induce  the 
opei-ator  to  be  less  thorough,  and  hurry  through  the  operation.  In  using 
the  sharp  curette  in  the  uterine  cavity,  anesthesia  is  always  advisable.    The 


820  MINOK    GYNECOLOGICAL    MANIPULATIONS. 

mere  act  of  curetting  should  not  occupy  longer  tlian  five  minutes,  the  check- 
ing of  the  bleeding  and  the  careful  tamponade  of  the  cervix  with  zinc- 
cotton  and  of  the  vagina  with  soda-disks  occupying  fully  as  much  more 
time. 

Dangers. — I  have  done  this  operation  many  times,  and  have  seen  no 
unpleasant  reaction  follow  it,  except  in  one  instance.  This  occurred  in 
London,  where  I  was  visiting  the  hospitals  at  the  time.  Di'.  Alfred  Wilt- 
shire requested  me  to  operate  on  a  patient  of  his  in  the  West  London  Hos- 
pital ;  I  removed  a  large  quantity  of  soft  medullary  tissue  as  far  up  as  the 
internal  os,  and  applied  a  tampon  saturated  in  a  weak  solution  of  perchlo- 
ride  of  iron.  A  violent  peritonitis  came  on  two  days  later,  and  on  the  tenth 
day,  amid  severe  expulsive  pains,  a  copious  discharge  of  fetid  fluid  took 
place,  and  with  it  was  discharged  a  solid,  pear-shaped  body,  which  proved  to 
be  aU  that  Avas  left  of  the  uterus  after  the  removal  of  the  cancerous  cervix. 
The  patient  recovered  from  the  peritonitis,  and  a  subsequent  digital  ex- 
amination revealed  entire  absence  of  the  uterus,  and  the  vaginal  roof  closed 
by  cicatricial  tissue.  The  cancer  returned  in  the  cicatrix  after  a  few  months, 
and  the  patient  died.  This  sloughing  out  of  the  whole  uterus  is  very  rai'e, 
only  four  other  cases  having  been  reported,  so  far  as  I  know  (Barker's, 
Mettauer's,  Habit's,  and  Martin's). 

The  danger  of  wounding  the  peritoneum  need  not  be  dreaded,  unless 
the  tissue  separating  it  from  the  seat  of  disease  has  become  extraordi- 
narily thin.  This  may  be  the  case  both  in  the  cervix,  when  the  disease 
has  invaded  the  whole  organ  and  the  scoop  removes  almost  the  entire  cer- 
vix, or  in  the  uterine  cavity,  where  the  sharp  scoop  should  always  be  used 
with  great  caution. 

The  removal  of  healthy  uterine  tissue  even  with  the  sharp  scoop  is 
scarcely  to  be  feared,  its  density  being  ordinarily  a  sufiicient  protection 
against  such  an  accident.  When  the  tissue  begins  to  creak  under  the 
strokes  of  the  curette  we  may  feel  sure  that  sound  substance  has  been 
reached,  and  our  object  should  be  to  obtain  this  creaking  sound  all  over 
the  diseased  surface,  before  all  the  cancerous  tissue  removable  by  the  cu- 
rette can  be  considered  destroyed.  To  follow  uj)  the  ramifications  of  the 
malignant  cells  along  the  lymphatics  and  among  the  stroma  of  the  uterus 
by  the  curette  (or  any  other  means)  is  beyond  our  power,  and  we  can, 
therefore,  hope  for  none  but  temporary,  palliative  results  after  curetting 
and  cauterization  of  the  womb. 

During  the  winter  of  1881-82  a  fatal  case  of  secondary  hemorrhage  af- 
ter amputation  of  an  epitheliomatous  cervix  with  the  galvanic  wire,  and 
subsequent  sharp  cu.retting  and  searing  with  Paquelin,  took  place  in  my 
clinic  at  the  College  of  Physicians  and  Surgeons.  No  blood  whatever  es- 
caped after  the  amputation,  but  the  curetting  ojpened  a  small  artery  at  the 
left  of  the  cervix,  all  hemorrhage  from  which  was  thoroughly  arrested  by 
Paquelin  before  the  patient  was  securely  tamponed  with  alum  cotton.  She 
did  perfectly  well  for  forty-four  hours,  when,  after  the  removal  of  the  tam- 
pons, which  were  perfectly  dry,  and  introduction  of  fresh  tampons,  a  vio- 
lent hemorrhage  set  in  which^  although  arrested  for  twenty-four  houi's,  then 


LOCAL    DEPLETIOISr    OF    THE    UTERUS.  321 

again  began,  was  found  to  be  uncontrollable,  and  proved  fatal  seventj'-six 
hours  after  the  operation.  Here  obviously  not  the  cautery  wire,  but  the 
sharp  curette  and  the  deep  slough  caused  by  the  Paquehn,  which  opened 
a  branch  of  the  uterine  artery  and  a  jjlexus  of  veins,  were  to  blame  for 
the  hemorrhage.  I  have  since  performed  precisely  the  same  operation 
some  twenty  times,  twice  also  opening  a  small  arterial  branch  with  the 
curette,  but  in  no  case  did  a  secondary  hemorrhage  ensue.  The  possibility 
of  cutting  an  artery  with  the  sharp  curette  should  be  borne  in  mind, 
especially  in  these  cases  of  cancerous  softening  of  vessels  and  stroma. 


IX.    LOCAL   DEPLETION   OF   THE  UTERUS. 

Blood  may  be  drawn  from  the  uterus  in  two  ways,  either  by  leeches  ap- 
plied to  the  cervix,  or  by  punctures  of  the  cervix  and  endometrium — scari- 
fication. 

The  indications  for  local  depletion  are  twofold  :  1,  to  disgorge  the 
loaded  uterine  or  pelvic  vessels,  in  acute  inflammation,  or  chronic  hyper- 
emia ;  and  2,  to  stimulate  the  sluggish  circulation,  either  by  unloading 
ectatic  veins  and  the  resultant  immediate  influx  of  a  fresh  stream,  or  by 
the  nervous  shock  of  the  depletion. 

Conditions  of  the  first  variety  are  :  acute  metritis,  endometritis,  and  en- 
dotrachelitis.  Acute  ovaritis,  pelvic  cellulitis,  and  peritonitis  might  well 
indicate  the  local  abstraction  of  blood ;  but  the  application  of  the  leeches, 
or  the  performance  of  scarification,  both  being  done  through  a  speculum, 
entail  so  much  disturbance,  to  the  patient  that  dej^letion  by  leeches  and 
blisters  to  the  skin  of  the  abdomen  are  to  be  preferred. 

A  more  common  indication  for  local  depletion  is,  however,  the  passive 
hyperemia  of  all  the  pelvic  veins,  which  is  almost  inseparable  fi-om  subin- 
volution and  areolar  hyperplasia  of  the  uterus.  The  puffy,  swollen  ap- 
pearance, and  purple  color  of  the  cervix,  the  succulent,  spheroid  feel  of  the 
body  of  the  uterus,  and  the  sensation  of  weight,  bearing-down,  and  fulness 
in  the  pelvis,  are  symptoms  calling  for  an  unloading  of  the  utei'o-pelvic  ves- 
sels. When  and  how  often  to  perform  this  maneuvre  is  the  question  to  be 
decided  in  each  individual  case.  While,  in  acute  conditions  one  or  two 
depletioDs  (and  it  may  be  as  well  to  say  here  that  leeches  are  preferable 
under  such  circumstances)  will  generally  suffice,  in  chronic,  passive  hyper- 
emia— subinvolution,  areolar  hyperplasia,  chronic  endometritis,  and  endo- 
trachelitis — the  abstraction  of  blood  should  be  repeated  at  intervals  of 
once  a  week,  more  or  less  ;  in  these  latter  conditions,  scarification,  while, 
perhaps,  not  quite  as  efiectual,  is  greatly  more  convenient  and,  for  various 
reasons,  to  be  preferred. 

Of  the  value  of  local  depletion  in  acute  affections  of  the  uterias  there 
can  be  no  doubt ;  whether  the  object — the  unloading  of  the  blood-vessels 
and  reduction  of  inflammation — cannot  be  as  well  accomplished  by  contract- 
ing the  vessels  by  hot  injections  and  abdominal  applications,  must  be  de- 
cided by  the  physician.  If  there  is  no  counter-indication,  the  most  rapid 
21 


322  MIlSrOR    GYNECOLOGICAL    MANIPULATIOiSTS. 

effect  will  doubtless  be  produced  by  the  leeches,  which  may  and  probably 
should  be  followed  by  the  hot  remedies. 

Whether  local  depletion,  however,  is  so  positively  beneficial — perma- 
nently beneficial,  at  least,  in  the  chronic  conditions  afore-mentioned — is 
by  no  means  so  certain.  The  opinions  are  still  divided  as  to  whether  it 
does  any  permanent  good  to  abstract  an  ounce  or  two  of  blood  eveiy  week 
or  two  from  a  hj-perplastic  uterus,  whether  the  enlargement  is  in  any  man- 
ner reduced  thereby,  and  the  patient  gradually  restored.  The  disbelievers 
in  the  practice  assert  that  the  unloading  of  the  blood-vessels  is  but  mo- 
mentary, and  that  the  uterus  immediately  regains  its  former  blood  quan- 
tity ;  that  absorption  of  the  hyperplastic  tissue  is  not  shown,  by  experience, 
to  be  hastened  by  the  abstraction  of  blood.  It  must  be  admitted  that  a 
cure  will  probably'  not  be  obtained  in  old  inveterate  cases  of  hyperplasia  by 
this  or  any  other  means.  But  experience  has  proved  to  me,  as  to  many 
others  who  favor  local  bloodletting,  that  the  unquestionable  temporary 
relief  given  by  the  abstraction  of  at  least  two  ounces  of  blood  from  the 
cervix  continues  for  some  days  or  weeks,  and  that  this  practice,  frequently 
repeated,  will  not  only  allay  many  of  the  local  and  constitutional  symptoms 
(fulness,  weight,  nervousness,  neuralgiae),  but  will  assist  the  hot  injections, 
iodine  applications,  and  glycerine  tampons  in  accomplishing,  after  a  time, 
what  reduction  in  size  and  resolution  of  adventitious  tissue  may  be  ex- 
pected in  this  obstinate  affection.  In  the  absence  of  other  more  jDositive 
remedies,  it  is  certainly  proper  to  employ  any  safe  measure  which  may 
possibly  be  beneficial, 

2.  The  second  indication,  that  of  stimulating  the  pelvic  circulation,  ob- 
tains in  amenorrhea  from  chronic  pelvic  hyperemia  (also  found  in  subin- 
volution and  hyperplasia),  and  from  deficient  development  of  the  uterus. 
In  the  former  cases  the  unloading  of  the  enlarged  veins  and  capillaries  of 
their  sluggish  contents,  in  the  latter  the  shock  to  the  pelvic  vaso-motor 
nerves,  appears  to  be  the  manner  in  which  the  deijletion  acts.  In  both 
classes  leeches  are  the  preferable  means,  but  scarification  will  often  be  suc- 
cessful. The  result  of  such  applications,  made  shortly  before  the  expected 
menstrual  period,  which  may  or  may  not  appear,  and  is  usually  scanty, 
will  in  the  first  variety  very  commonly  be  followed  by  a  normal  flow  two 
or  three  days  later.  In  deficient  development  the  treatment  will  need  to 
be  more  prolonged  and  more  frequently  repeated  to  do  good. 

The  peculiar  cu'cumstance,  that  the  flow  of  blood  from  the  punctures 
will  usually  cease  as  soon  as  the  patient  leaves  the  table,  and  that  the 
normal  menstrual  dischai-ge  will  come  on  several  days  later,  if  the  opera- 
tion was  done  at  the  proper  time,  should  be  remembered,  and  the  patient 
cautioned  not  to  be  discouraged  if  she  finds  the  flow  arrested  when  she 
reaches  home. 

The  amount  of  blood  to  be  taken  at  each  sitting  will  vaiy  from  one 
to  two  ounces.  This  is  quite  sufl&cient  to  produce  the  desired  local  effect, 
and  even  if  repeated  as  often  as  twice  a  week  cannot  weaken  the  patient. 
To  be  of  service  in  chronic  cases  the  depletion  should  be  practised  at  least 
once  a  week  for  several  months. 


LOCAL    DEPLETIOlSr    OF    THE    UTERUS.  323 

Counter-indications  and  Dangers. — If  the  rules  given  tinder  indications 
be  carefully  observed,  there  are  but  few  circumstances  which  would  pre- 
vent local  depletion.  One  of  these  is  the  jDresence  of  a  hemophilic  ten- 
dency in  the  patient.  A  woman  who  bleeds  profusely  from  every  needle- 
puncture  or  abrasion,  should  of  course  not  be  subjected  to  the  risk  of  a 
possibly  serious  hemorrhage  from  a  puncture  of  her  uterus.  The  inad- 
visabihty  of  producing  an  influx,  of  fresh  blood  in  extensive  chronic  or 
subacute  pelvic  inflammation  has  been  spoken  of ;  we  can  never  tell 
whether  that  influx  may  not  rekindle  the  inflammation  as  well  as  refill  the 
uterus. 

A  varicose  vein  on  the  cervix  may  be  bitten  by  a  leech  or  punctured, 
and  quite  profuse  hemorrhage  ensue.  Or,  the  nerve-shock  from  the  leech- 
bites  may  show  itself  in  general  erythema  or  urticaria,  as  was  observed  by 
Scanzoni,  Veit,  Leopold,  and  others  ;  and  hysterical  symptoms  of  various 
kinds  may  also  arise.  Such  accidents  usually  occur  after  leeching,  rarely 
after  scarification.  Pregnancy  must  certainly  be  looked  upon  as  a  counter- 
indication  ;  indeed,  what  could  be  the  use  of  reducing  physiological  hyper- 
emia of  the  uterus  peculiar  to  that  state  ? 

When  a  counter-indication  exists  to  the  abstraction  of  blood  from  the 
cervix,  or  leeches  seem  necessary,  and  cannot  be  applied  to  the  uterus  (as 
in  a  narrow,  constricted  vagina  in  virgins,  where  a  speculum  cannot  be  in- 
troduced), the  leeches  may  be  placed  on  the  labia  majora,  perineum,  thighs, 
or  about  the  anus.  But  it  should  be  remembered  that  an  opening  of  one 
of  the  large  veins  found  at  any  of  these  regions  may  result  in  very  severe 
hemorrhage. 

Application  of  Leeches. — The  only  manner  of  applying  leeches  to  the 
cervix  is  through  a  cylindrical  speculum.  A  tube  of  sufficient  size  to 
closely  fit  around  the  cervix  should  be  chosen,  and  care  taken  that  no  fold 
of  the  vagina  to  which  a  leech  might  attach  itself  protrudes  into  the 
lumen.  (The  large  veins  in  the  vaginal  walls  render  the  application  of 
leeches  to  them  unadvisable.)  When  the  cervix  has  been  well  fitted  iuto 
the  speculum,  it  is  wiped  clean  and  dry,  and  the  external  os  plugged  with 
a  small  tent  of  cotton  inserted  on  a  slide-applicator  and  cut  off  smoothly 
with  scissors  at  the  level  of  the  surface,  or  by  the  end  of  a  sj^onge-tent. 
This  is  done  to  prevent  a  leech  from  crawling  into  the  uterine  cavity,  an 
accident  which  may  produce  severe  uterine  colic,  hemorrhage,  and  shock. 
If  this  should  occur,  the  leech  may  be  stupefied,  by  gently  injecting  a  few 
drops  of  salt-water  into  the  uterine  cavity,  and  then  seized  with  long,  thin 
dressing-forceps  and  withdrawn,  or  be  left  to  the  expulsive  efforts  of  the 
uterus.  While  not  a  dangerous  accident,  its  occux'rence  is  unpleasant,  be- 
cause it  delays  the  operation,  causes  annoyance  to  physician  and  patient, 
and  may  give  rise  to  considerable  pain.  Obviously,  the  leech,  living  or 
dead,  cannot  be  left  in  utero  for  an  indefinite  period.  It  must  be  removed 
before  the  physician  takes  his  leave.  Weber  recommends  passing  a 
threaded  needle  through  the  tail  of  each  leech  before  putting  it  iuto  the 
speculum,  and  to  guard  against  its  escape  by  holding  the  string  in  the 
hand.     The  efficiency  of  the  leeches  is  said  not  to  be  diminished  by  this 


324 


MINOR    GYNECOLOGICAL    3IANIPULATI0NS. 


practice.  It  certainly  would  be  effectual  in  preventing  their  escape.  The 
number  of  leeches  should  be  counted,  as  they  are  introduced,  in  order  that 
the  physician  may  be  sure  of  having  removed  all  when  the  operation  is 
completed.  These  prehminaries  arranged,  the  leeches  are  jDut  into  the 
speculum  with  the  fingers,  and  pushed  up  with  a  moist  sponge  on  a  holder 
or  a  pledget  of  cotton  in  the  dressing-forceps,  until  they  reach  the  cervix. 
The  cotton  is  then  left  in  the  speculum  in  order  to  prevent  the  escape  of 
the  leeches.  The  mouth  of  the  speculum  should  be  closely  watched,  as  a 
leech  may  very  easily  slii^  out  beside  the  cotton,  and  attach  himself  to 
some  other  portion  of  the  patient's  body  near  by  which  happens  to  be  ex- 
posed, or  fall  on  the  floor  and,  if  the  animal  has  already  drawn  blood,  soil 
the  carpet.  As  a  rule,  leeches  bite  very  readily  at  the  cervix.  If  they  do 
not,  a  few  slight  punctures  of  the  cervix  will  draw  blood  enough  to  attract 
the  leeches.  After  a  few  minutes  it  is  well  to  remove  the  cotton,  and  see 
whether  the  leeches  have  bitten.  A  shght  pain,  and  a  drawing,  unpleas- 
ant sensation  in  the  pelvis  are  all  the  patient  feels  of  the  bite.  Generally 
not  more  than  three  or  four  leeches  are  appUed,  because  these  wiU  remove 
all  the  blood  required,  and  no  more  have  room  in  the  speculum.     Each 


ri"!.  161. — Koese's  Artificial  Leech. 

leech  draws  on  an  average  half  an  ounce  of  blood,  and  two  ounces  are 
probably  as  much  as  need  be  taken  at  each  sitting.  Besides,  the  loss  from 
after-oozing  may  amount  to  an  ounce  or  two  more. 

When  a  leech  is  satisfied  it  loosens  its  hold  and  is  removed  from  the 
speculum  by  depressing  its  mouth,  and  sliding  the  leech  into  a  cup  or  bowl, 
together  with  whatever  blood  has  escaped.  Thus  leech  after  leech  is  re- 
moved. Generally  fifteen  to  twenty  minutes  will  suffice  to  complete  the 
operation,  if  every  leech  tahes  prompt  hold.  This  they  often  fail  to  do, 
and  the  operation  may  be  greatly  delayed  thereby.  When  a  leech  once 
refuses  to  bite,  the  chances  are  that  it  will  not  be  induced  to  do  so,  and  a 
fresh  one  had  better  be  substituted. 

When  the  leeches  have  all  been  removed,  the  blood  is  mopped  out  of 
the  speculum  and  the  cervix  examined,  to  see  whether  any  larger  vessel 
has  been  opened,  or  the  bleeding  is  profuse.  If  so,  an  alum  or  tannin 
pledget  may  be  placed  over  the  cervix.  If  slight,  the  speculum  is  with- 
drawn, and  the  patient  directed  to  check  any  excessive  secondary  hemor- 
rhage by  astringent  injections,  and  in  case  of  need  send  for  the  physician. 
Leech-bites  are  often  followed  by  more  or  less  profuse  oozing  for  sevei-al 
hours,  and  Avhile  this  is  one  of  the  advantages  of  this  method  of  dej)letion, 
it  should  not  be  allowed  to  continue  so  long  as  to  weaken  the  patient.  If 
the  oozing  is  too  slight,  tepid  injections  should  be  ordered.  The  appli- 
cation of  leeches  should  always  be  made  at  the  home  of  the  patient. 

Unquestionably,  the  suction  action  of  the  leeches  draws  more  blood 


LOCAL  DEPLETION  OF  THE  UTERUS.  325 

from  the  "uterine  vessels  than  is  obtained  by  mere  shai-p  punctures.  In 
acute  inflammations,  and  when  the  hyperemia  is  excessive,  this  suction 
and  the  secondary  oozing  are  desii*able.  But  the  question  is  whether  in 
chronic  hyperemia  the  influx  of  blood  into  the  momentarily  unloaded 
veins  is  not  increased  by  the  suction  of  the  leech,  and  the  benefit  of  the 
application  counterbalanced.  So  much  is  certain,  that  when  we  want  a 
thorough  disgorgement  of  the  blood-vessels,  the  leech  is  the  proper  agent. 
The  instrument  shown  in  Fig.  161  is  intended  to  act  as  a  substitute  for  the 
leech.  The  cervix  having  been  punctured  with  the  lance-shaj)ed  needle, 
the  latter  is  withdrawn,  the  suction-tube  screwed  down,  and  the  piston 
drawn  back.  I  do  not  think  this  contrivance  has  become  popular.  The 
inconvenience  attending  the  employment  of  leeches,  the  length  of  time 
required,  their  expense  (a  matter  of  some  importance  to  poor  patients), 
and  the  danger  of  the  bites  bleeding  too  long,  all  these  objections  have 
led  to  the  popularization  of  another  method  for  depleting  the  uterus  and 
adnexa,  namely. 

Scarification. — This  may  be  either  superficial  or  deep.  If  superficial, 
the  incisions  are  made  with  an  ordinary  long-handled,  sharp-j^ointed 
bistoury,  which  is  thrust  into  the  tissue  of  the  intra-vaginal  portion  of  the 
cervix,  to  the  depth  of  one-eighth  of  an  inch,  or  with  which  the  cer^dx  is 


SE3^ 


Fig.  162.— Buttles'  Scarificator. 

gashed  in  a  radiating  direction  from  the  os,  outward  ;  five  or  six  or  more 
such  incisions  may  be  made.  Relief  of  tension,  splitting  of  occluded  mucip- 
arous follicles  (ovula  Nabothi),  and  quite  free  bleeding,  especially  from 
the  cuts  near  the  os,  result  from  these  incisions.  To  gash  the  cervix  in  all 
directions  with  a  dull-pointed  curved  knife  seems  to  me  unadvisable,  be- 
cause the  incisions  are  not  deep  enough  to  draw  much  blood,  and  because 
the  linear  cicatrices  resulting  will  after  a  while  contract  and  disfigure  the 
mucous  membrane  covering  the  cervix. 

If  deep  incisions  or  punctures  are  desired,  a  fine-pointed  bistoury  may 
be  used,  or,  Avhat  is  better,  a  regular  scarificator  with  lance-shaped  point  as 
shown  in  Fig.  162.  This  needle  is  thrust  into  the  cervical  tissue,  to  the 
depth  of  one-fourth  to  one-half  of  an  inch,  and  even  more,  care  being  taken 
to  keep  parallel  with  the  cervical  canal  in  oixler  to  avoid  wounding  the 
parametrium.  As  many  as  twenty  such  j^unctures  maybe  made  each  time, 
not  all  going  so  deep  as  one-half  of  an  inch,  in  proportion  to  the  size  of  the 
cervix  and  the  amount  of  blood  desii-ed  and  obtained.  The  flow  of  blood 
from  scarification  is  by  no  means  as  great  as  from  leech-bites.  I  have  fre- 
quently obtained  no  more  than  one  ounce  from  at  least  twenty  punctures. 
To  increase  this  flow,  the  scantiness  of  which  depends  partly  uj)on  the 
failure  to  wound  larger  vessels,  and  partly  upon  the  absence  of  suction- 
force  to  draw  the  blood  down  from  more  distant  channels,  various  con- 
trivances have   been   devised.      The    dry  cupping-tube  of  Thomas,    and 


326  MITTOR    GYNECOLOGICAL    MAIS-^IPULATIONS. 

Keese's  artificial  leech  (Fig.  161)  illustrate  the  principle  of  these  instru- 
ments. The  former  is  to  be  applied  to  the  cervix  both  before  and  after 
scarification,  precisely  as  a  cupping-glass  draws  the  blood  first  into  the 
skin,  and  then  out  of  the  incisions  which  have  in  the  interval  been  made 
in  the  hyperemic  tissue  by  the  cupper.  Although  the  idea  is  an  iugenious 
one,  the  practice  has  not,  so  far  as  I  am  aware,  been  generally  adopted,  al- 
though the  instrument  is  figured  in  every  work  on  gynecology.  Injections 
of  warm  (not  hot)  water  are  almost  always  needed  after  scarification  to  in- 
crease and  maintain  the  flow  for  a  few  hours  at  least. 

Besides  the  mere  withdrawal  of  blood,  scarification  and  puncture  ex- 
ert an  exceedingly  favorable  influence  on  uterine  congestion  by  unloading 
the  numerous  Uttle  muciparous  folhcles  which  stud  not  only  the  surface 
of  nearly  every  hyperplastic  uterus,  but  often  extend  some  distance  up  the 
cervical  canal.  These  little  glands,  if  at  all  prominent,  feel  to  the  exam- 
ining finger  hke  shot  buried  under  the  mucous  membrane,  and  are  a  con- 
stant source  of  irritation  of  the  cervix,  and  thereby  of  the  whole  uterus, 
constituting  a  variety  of  disease  known  as  cystic  hyperplasia  of  the  cervix. 
If  very  large  and  numerous,  their  peculiar  nodular  feel  may  even  simulate 
carcinoma,  from  which  their  softness  chiefly  distinguishes  them.  On  the 
surface  they  appear  to  the  eye  as  smaU  semi-opaque  dots,  from  which  on 
puncture  a  drop  of  viscid,  glairy  mucus  oozes.  The  jDuncture  of  these  fol- 
licles, which  are  nothing  but  minute  retention  cysts — indeed  the  destruc- 
tion of  their  wall  by  a  cutting  or  twisting  motion  of  the  scaiificator — rap- 
idly reduces  an  engorged  cervix.  They  are  particularly  numerous  in 
aversion  of  the  endotrachelian  mucous  membrane  from  laceration  of  the 
ceiwix,  and  unless  thoroughly  destroyed  by  repeated  puncture  will  mate- 
rially interfere  with  union  after  the  operation  of  the  laceration.  Even  the 
removal  of  the  superficial  layer  of  the  cervical  mucosa  covering  the  everted 
lips,  as  is  done  during  the  operation,  does  not  always  destroy  these  cysts, 
since  the  cut  may  simply  divide  them  in  the  middle,  and  leave  one-half  as  a 
secreting  stu'face  between  the  lips  of  the  wound.  The  glands  must  be  ob- 
literated by  a  thorough  destruction  of  their  walls,  and  carbolic  acid,  iodized 
phenol,  or  even  soHd  nitrate  of  silver  may  be  needed  to  accomplish  this. 
Better  a  cicatrix,  which  can  be  entirely  removed,  than  a  hidden  secreting 
surface.  The  puncture  of  these  follicles  may  have  to  be  repeated  several 
times  a  week  until  all  are  destroyed. 

Scarification  of  the  mucous  membrane  of  the  uterine  cavity  proper  is 
not  quite  so  innocuous  as  that  of  the  cervix,  but  it  may  be  unavoidable 
when  puncture  of  the  cervix  does  not  abstract  sufficient  blood.  It  is  per- 
formed with  a  long  hollow  sound-shaped  tube,  from  the  side  of  the  distal 
end  of  which  a  fine  blade  is  protruded  by  a  screw  in  the  handle  when  the 
instrument  is  in  the  uterine  cavity.  By  turning  the  blade  about  from  side 
to  side,  the  mucous  membrane  is  gently  incised  as  much  as  appears  neces- 
sary. In  obstinate  amenorrhea,  chiefly  with  hyperplastic  uterus,  this  intra- 
uterine scarification  may  be  required,  and  prove  veiy  useful.  In  place  of 
the  knife,  I  have  successfully  emploj'ed  the  steel  tampon-screw  shown  in 
Fig.  97,  gently  twisting  the  screw  about  in  the  uterine  cavity,  and  thereby 


INJECTIONS    INTO    THE    TISSUE    OF    THE    CERVIX.  327 

lacerating  the  blood-vessels.  Of  course,  care  must  be  taken  not  to  bore 
the  point  of  the  screw  into  the  wall  of  the  organ. 

Scarification  may  be  practised  through  any  form  of  speculum,  but  the 
tubular  is  preferable,  as  it  permits  the  more  neat  and  convenient  removal 
of  the  blood,  which  is  allowed  to  flow  or  is  mopped  into  a  cup  held  under 
the  mouth  of  the  speculum,  Unhke  leeching,  scarification  may  be  safely 
and  conveniently  practised  at  the  oflfi.ce  or  out-door  clinic.  It  is  not  espe- 
cially painful,  although  patients  almost  always  feel  every  puncture,  and 
some  complain  decidedly.  But  the  operation  is  so  short,  and  involves  so 
little  other  trouble  that  they  never  object  to  this  trifling  pain.  When  I 
scarify  at  my  oflfi.ce  I  usually  insert  a  pledget  of  glycerine  in  order  to  pre- 
vent the  blood  from  escaping  and  soiling  the  linen,  and  also  to  induce  a 
watery  discharge,  and  tell  the  patients  to  remove  the  cotton  as  soon  as 
they  return  home,  and  promote  the  flow  by  tepid  injections.  Constant 
mopping  of  the  cervix  and  removal  of  the  blood  from  the  speculum  will 
aid  the  flow,  but  I  generally  find  that  very  little  escapes  when  the  specu- 
lum is  removed.  It  is  well  to  tell  the  patients  afterward  that  blood  has 
been  drawn,  that  they  have  been  cupped,  or  the  blood  which  might  show 
itself  during  the  day  will  alarm  them. 

The  good  efl:ects  of  scarification  in  promoting  a  scanty  menstrual  flow 
often  do  not  appear  until  several  days  later,  the  momentary  dischar^-e 
having  entirely  ceased  in  the  meanwhile.  Warm  injections,  foot-baths  and 
sitz-baths  are  indicated  in  these  particular  cases  until  the  regular  flow  ap- 
pears. The  injections  should  not  be  of  hot  water,  which  would  contract 
the  capillaries.  No  evil  results  have,  to  my  knowledge,  ever  ensued  from 
scarification  properly  performed. 

X.     INJECTION   OF  MEDICINAL   SUBSTANCES  INTO   THE   TISSUE  OF  THE 

CERVIX  AND  VAGINA. 

Impressed  with  the  idea  that  the  injection  of  a  few  drops  of  alterative 
and  stimulant  agents  into  the  tissue  of  the  cervix  itself  might  prove  as 
beneficial  in  chronic  h;^TDerplasia  of  the  cervix  and  body  of  the  uterus  as  it 
does  in  chronic  hypertrophy  of  the  tonsils,  I  had  a  long  hypodermic  needle 
made  several  years  ago,  and  began  to  experiment  on  a  few  aiDpropriate 
patients  in  my  clinic.  I  liaiDpened  to  have  a  few  very  intractable  eases  of 
general  areolar  hyperplasia,  as  indeed  is  generally  the  case,  and  I  deter- 
mined to  see  whether  the  patients  would  endure  and  be  benefited  by  in- 
jecting tincture  of  iodine  or  fluid  extract  of  ergot,  which  seemed  to  me  the 
most  suitable  drugs,  deep  into  the  tissue  of  the  cervix.  Accordingly,  at 
alternate  visits  of  one  week  ajoart,  I  injected  five  drops  of  iodine  and  five 
drops  of  a  hypodermic  solution  of  ergot  (one  grain  of  Squibb's  solid  aque- 
ous exti-act  of  ergot  to  two  minims  of  water)  deep  into  the  cervix,  plung- 
ing the  needle  at  least  one-half  inch  deep  into  the  tissue  straight  upward 
toward  the  internal  os,  and  slowly  expressing  the  fluid.  The  injections 
were  made  in  the  out-door  clinic,  and  but  little  pain  was  complained  of  at 
the  time.     The  patients  were  allowed  to  return  home  a  short  time  after  the 


328  MINOR    GYNECOLOGICAL    MANIPULATIONS. 

injection.  Soon  after  I  began  tlie  practice,  I  chanced  to  speak  of  the  plan 
to  Dr.  Wm.  T.  Lusk,  and  was  informed  by  him  that  the  same  idea  had 
been  carried  out  some  years  before  in  Bellevue  Hospital  by  one  of  the  in- 
ternes, and  that  the  result  had  been  a  post-mortem  for  peritonitis.  I  still 
persisted,  however,  until  I  had  given  three  injections  of  iodine  and  ergot 
alternately  to  each  of  four  patients,  when  one  injection  of  iodine  produced 
such  violent  pain  and  para-uterine  tenderness  that  I  became  alarmed,  not 
wishing  to  meet  with  the  same  results  as  the  Bellevue  gentleman.  The 
patient  recovered  under  rest  in  bed  and  hot  fomentations,  but  I  decided  to 
defer  my  experiments  v^dth  this  method,  and  have  not  since  recommenced 
them.  In  no  case  was  there  any  improvement  in  size  of  uterus  or  symp- 
toms noticeable. 

While  I  was  making  this  trial,  and  anticipated  from  its  painlessness 
that  good  results  might  be  achieved.  Dr.  J.  M.  Bennett,  of  Liverpool,  re- 
ported an  almost  identical  method  in  chronic  cervical  metritis.  He  used 
a  solution  composed  of  grs.  xx.  each  of  iodide  and  bromide  of  potash, 
one-half  drachm  tincture  of  iodine,  two  drachms  of  water  and  glycerine, 
and  injected  a  few  drops'  in  five  or  six  different  spots,  according  to  the 
size  of  the  cervix.  Scarification  of  the  cervix  preceded  the  injection.  No 
reaction  was  observed  in  any  case.  Three  operations  were  generally  suffi- 
cient, and  he  effected  many  cures  by  this  method.  As  soon  as  the  imme- 
diate effect  of  the  injection  had  passed  away  the  cervix  was  dilated  by  a 
sponge -tent. 

Dr.  L.  J.  Collins,  of  GuiKord,  Ind.,  has  also  recommended  the  same 
treatment,  using  a  solution  of  ergot,  two  and  a  half  grains  to  the  injection, 
a  pledget  of  cotton  soaked  in  chloroform  having  first  been  placed  to  the 
cervix  as  an  anesthetic.  He  reports  excellent  results,  making  the  injec- 
tions every  five  or  six  days,  for  two  to  three  months.  The  patients  were 
kept  in  bed  for  twenty-fours  hours  after.  No  unpleasant  reaction  ensued 
in  any  case. 

Dr.  Delore,  of  Paris,  reported  sixty-three  cases  in  1877  of  ergotine  in- 
jections into  the  uterine  tissue  ;  the  solution  used  was  of  a  strength  of  1 :  2. 
The  patients  were  frequently  seized  with  nausea,  chills,  vomiting,  and  pain 
in  the  head,  back,  and  abdomen,  which  lasted  from  four  to  twenty-four 
hours.  Twice  an  abscess  occurred  in  the  cervix,  once  a  pelvic  cellulitis. 
The  results  were  certainly  not  as  satisfactory  as  those  obtained  by  hypo- 
dermic injections  of  the  same  drug ;  still,  hemorrhage  was  soon  arrested, 
tumors  ceased  to  grow,  and  the  general  health  of  the  patients  improved. 

Encouraged  by  these  reports  I  have  been  endeavoring  to  make  up  my 
mind  to  resume  the  injections.  The  only  difficulty  against  practising  them 
in  an  out-door  clinic  is  that  I  deem  it  absolutely  essential  to  safety  that  the 
patient  should  remain  in  bed  for  at  least  twenty-four  hours  afterward.  If 
positive  benefit  both  as  regards  the  symptoms  and  the  diminution  in  size 
of  a  subinvoluted  or  hyperplastic  uterus  could  be  hoped  for  from  these  in- 
jections, they  certainly  should  be  given  a  fair  trial,  since  so  Httle  real  good 
can  be  done  these  cases  by  the  means  hitherto  at  our  disposal. 

Injections  into  the  substance  of  the  vaginal  wall  for  mahgnant  disease 


REPOSITION    OF    DISPLACED    UTERUS    AND    OVARIES.         329 

and  for  the  deposits  of  chronic  pelvic  celluHtis  have  been  made  by  Dr.  Wm. 
M.  Chamberlain,  of  New  York.  He  uses  an  alcohoKc  solution  of  bromine 
(1 : 5),  injecting  five  drops  into  the  neoplasm  every  two  or  three  days,  and 
reports  decided  shrinkage  of  the  tumor.  I  am  not  aware  that  this  practice 
has  been  followed  by  other  operators,  nor  whether  its  success  entitles  it  to 
commendation. 

A  solution  of  chloride  of  zinc  (1  :  5)  may  be  injected  into  the  paren- 
chyma of  a  cancerous  cervix  for  the  jDurpose  of  producing  sloughing  of  a 
portion  of  the  growth.  Five  to  ten  di'ops  may  be  injected  one-foxu'th  to 
one-half  an  inch  deep.  This  should  be  done  at  the  home  of  the  patient 
and  precautions  taken  against  possible  hemorrhage  from  erosion  of  a 
vessel  during  separation  of  the  slough.  Such  an  accident  hajDjoened  to  me 
on  one  occasion,  and  the  patient  lost  considerable  blood  before  I  reached 
her  and  tamponed  the  vagina.  Pure  carbolic  acid  may  be  injected  for  a 
like  purpose,  and  in  the  same  manner ;  this  agent  acts  besides  as  a  local 
anesthetic.  An  erosion  of  a  vessel  is  not  to  be  feared  from  the  slou^-hino- 
after  the  carbolic  acid  injection. 

The  injection  of  escharotics  into  a  fibroid  tumor  is  not  advisable  ;  the 
danger  of  septicemia  by  far  outweighs  any  advantage  in  shrinkage  of  the 
tumor  which  might  possibly  ensue. 

XI.    REPOSITION  OF   THE   DISPLACED   UTERUS   AND   OVARIES. 

As  a  rule,  every  dislocated  uterus  should  be  replaced  whenever  its  dis- 
location gives  rise  to  sj^mptoms,  or  a  supporter  is  to  be  introduced  to 
maintain  it  in  its  normal  position. 


Fig.  163.— Anteflexion  of  Uteni?,  First  De-  FlG.  164.— Anteflexion  of  Uterus,  Second  De- 

gree (P.  F.  M.).  gree(P.  F.  M). 

The  replacement  of  an  anteverted  or  anteflexed  uterus  is  an  easy  mat- 
ter, but  as  soon  as  the  support  of  the  replacing  finger  is  withdrawn  the 
fundus  at  once  falls  forward  again  through  its  Aveight  and  normal  inclina- 
tion in  that  direction.  A  complete,  and  so  long  as  the  patient  retains  the 
dorsal  position,  permanent  replacement  can  be  obtained  only  by  retrovert- 
ing  the  uterus  by  manual  or  instrumental  measures. 


330 


MINOR    GYNECOLOGICAL    MANIPULATIONS. 


In  lateral  displacements  tlie  reposition  is  rarely  possible  except  by  force, 

for  the  reason  that  these  dislocations  are  generally  due  to  inflammatory 
contraction  of  the  broad  ligament  of  the  side  toward  which  the  fundus  in- 
clines. Only  by  gradually  stretching  this  adhesion  can  a  restoration  to 
the  median  line  be  effected. 

Li  retro-displacements  the  fundus  can  be  restored  with  more  or  less 
facility,  unless  it  is  bound  down  by  intra-peritoneal  adhesions.  In  this 
class  of  dislocations  the  uterus  once  replaced,  of  course,  assumes  the 
normal,  slightly  antecurved  position  (see  Fig.  14)  and  will  then  retain  this 
position  so  long  as  the  patient  does  not  rise  ;  in  rare  instances  when  the 
displacement  was  the  result  of  recent  physical  shock,  the  retention  may  be 
permanent.     Usually,  the  fundus  falls  back  again  as  soon  as  the  erect 


Pig.  165. — Anteflexion  of  Uterns,  Third 
Degree  (F.  F.  M.). 


Fig.  166. — Degrees  of  Anteversion  of  Uterus,  First  and  Sec- 
ond.    The  solid  outline  is  the  normal  position  (P.  P.  II. ). 


posture  is  assumed  and  the  abdominal  viscera  press  down  on  the  uterus. 
In  downward  disj)lacement,  j)rolapsus,  the  replacement  is  also  an  easy 
matter,  as  soon  as  intra-abdominal  pressure  is  suspended  in  the  dorsal  or 
knee-chest  position. 

The  reduction  of  an  inverted  uterus  can  scarcely  be  considered  to  be- 
long under  minor  surgical  gynecology,  as  it  is  generally  a  difficult,  severe, 
and  protracted  operation.  I  include  it  here  for  the  sake  of  completeness, 
without  intending  to  give  the  minute  details  of  all  the  methods  now  em- 
ployed for  the  purpose. 

A  displaced  uterus  can  be  restored  to  its  normal  position  either  by  the 
aid  of  the  fingers,  or  by  gravitation  and  atmospheric  pressure,  or  by  in- 
struments. 

By  the  Fingers. 

Ante-displacements. — To  rejDlace  an  anteverted  or  anteflexed  uterus,  it 
is  but  necessary  to  put  the  patient  in  the  dorsal  recumbent  position  with 
elevated  thighs,  pass  the  index  finger  into  the  anterior  pouch  of  the  va- 
gina and  gently  press  the  fundus  upward  and  backward  until  the  exter- 


REPOSITION    OF    DISPLACED    UTERUS    AND    OVARIES.         331 

nal  hand  can  be  pressed  into  the  abdominal  wall  between  symphysis  and 
uterus,  and  aid  the  retroposition.  As  soon  as  the  fundus  is  steadied  by 
the  external  hand,  the  internal  finger  slips  behind  the  cervix  and  lifts  it 
upward  toward  the  symphysis,  thereby  carrying  the  fundus  into  retrover- 
sion. This  replacement  is,  of  course,  merely  temporary,  unless  maintained 
by  a  pessary  or  the  jDrolonged  dorsal  decubitus.  If  the  fundus  should  be 
bound  down  by  adhesions  to  the  bladder,  as  occasionally  occurs,  the  re- 
placement will  not  succeed.  In  anteflexion,  also,  a  straightening  of  the 
uterine  axis  will  be  achieved  by  digital  efforts  only  when  the  distortion  is 
recent  and  in  a  flabby  uterus.  In  congenital  or  chronic  anteflexion,  in 
which  the  uterine  tissue  at  the  angle  of  flexion  has  become  cicatricial  or 


Fig.  167.— Degrees  of  Retroversion  of  Uteros,  First.  Serond,  and  Third.    The  solid  outline  is  the  normal 

position  (P,  F.  M.). 

hypertrophic,  a  replacement  will  usually  be  possible  only  by  the  aid  of  in- 
struments. The  external  hand  affords  most  valuable  assistance  in  lifting 
up  and  steadying  the  fundus. 

Anterior  displacements,  in  my  opinion,  are  neither  so  productive  of  dis- 
tress nor  so  curable  by  treatment  as  the  backward  dislocations. 

Lateral  displacements  can  be  rectified  also  by  the  vaginal  finger  and  ex- 
ternal hand,  provided  the  adhesions  to  which  these  displacements  are  due 
are  not  too  firm.  Unfortunately  this  is  generally  the  case,  and  the  uterus 
may  be  restored  to  its  normal  position  only  to  snap  back  t5  its  displace- 
ment when  the  pressure  or  traction  is  removed. 

Betro-disjjlacements  are  by  far  the  most  common  of  the  deviations  of  the 
uterus  requiring  rectification.  The  displacement  may  be  restored  either 
on  the  back,  side,  or  in  the  knee-breast  position. 

When  the  patient  lies  flat  on  her  back,  the  retro  verted  or  retroflexed 


332  MINOR    GYNECOLOGICAL    MANIPULATIOlSrS. 

fundus  can  be  lifted  up  by  the  middle  finger,  while  at  the  same  moment  the 
index  pushes  the  cervix  back  toward  the  sacral  excavation.  As  soon  as 
the  fundus  rises  to  the  level  of  the  promontory  of  the  sacrum  the  external 
hand  seizes  it  and  draws  it  forward,  the  internal  finger  keeping  up  its  back- 
ward pressure  on  the  cervix.  This  maneuvre  will  usually  succeed  if  the 
uterus  is  not  too  heavj',  too  sharply  retro-displaced,  especially  retroflexed, 
and  if  the  cervix  projects  sufficiently  into  the  vagina  to  afford  a  handle  for 
the  replacing  finger.  In  the  case  of  a  uterus  with  a  short  intra- vaginal  por- 
tion of  the  cervix  the  long  lever  (body  and  fundus)  so  far  exceeds  the  short 
lever  (cervix)  as  to  render  a  replacement  on  the  back  almost  impossible 

by  digital  efforts.  Such  cases 
also  afford  but  Httle  chance  for 
retention  by  a  pessary. 

When  a  retro-displaced  uterus 
is  not  easily  replaceable  in  the 
dorsal  position,  and  this  very 
often  occurs,  the  best  method  is 
to  place  the  patient  in  the  left 
semi-prone  decubitus,  in  which  a 
moderate  amount  of  gravitation 
away  from  the  pelvis  is  obtained 
and  intra-abdominal  pressure 
"'":''""''  is   somewhat   diminished.      The 

'■"— — '^'  clothes  should  be  loosened  about 

Fig.  168. — De^ees  of  Retroflexion  of  TJtems.  First,  •    i  rm  l  i^i 

Second,  and  Third.     The  solid  outline  is  the  first  de-     the    WaiSt.         ihc     Operator    then 

^^^^  stands  behind  the  patient,  facing 

her  head,  introduces  the  index  and  middle  fingers  of  his  right  hand  into 
the  vagina  and  carries  them,  with  the  palmar  surface  backward,  behind  the 
cervix  into  the  posterior  vaginal  pouch.  He  now  pushes  up  the  disjolaced 
fundus  gently  but  firmly,  following  up  each  advantage  steadily,  but  using 
no  active  force,  and  always  keeping  the  fingers  pressed  against  the  poste- 
rior wall  of  the  uterus.  This  upward  pressure  may  be  made  at  intervals, 
or  continuously  ;  and  occasionally  a  few  quick  pushes  may  be  added  in  the 
hope  of  bounding  the  fundus  above  the  promontory.  The  pain  experienced 
during  this  maneuvre  may  be  trivial,  or  quite  severe  if  the  uterine  body  is 
congested  and  tender.  Besides,  the  pressure  against  the  perineum,  which 
is  forced  up  to  the  utmost  by  the  operator's  fingers,  causes  some  pain  both 
to  the  latter  and  the  patient,  \\lieu  the  fundus  has  been  so  far  elevated  as 
to  be  on  a  level  with  the  pi^omontory,  and  requires  but  a  slight  impulse 
forward  to  accomplish  the  replacement,  the  index-finger  quickly  seizes  the 
anterior  aspect  of  the  cervix,  while  the  middle  finger  still  supports  the  fun- 
dus, and  gently  but  firmly  draws  it  backward  ;  while  this  is  being  done  the 
middle  finger  also  seizes  the  cervix,  and  both  together  force  that  part  as 
far  as  possible  into  the  sacral  excavation.  The  fundus  being  thus  propelled 
forward  often  falls  with  a  jerk,  as  it  were,  into  anteversion.  Especially  does 
this  occur  if  the  organ  is  heavy  and  the  ligaments  lax.  Some  gynecolo- 
gists employ  the  left  hand  for  this  maneuvre,  the  operator  facing  the  pa- 


KEPOSITION    OF    DISPLACED    UTERUS    AND    OVARIES.         333 

tient's  genitals  and  inserting  the  two  first  fingers  of  that  hand  behind  the 
cervix  and  proceeding  precisely  as  described  for  the  right  hand.  It  is  true 
that  with  the  left  hand  a  much  greatei"  leverage  can  be  exerted  on  the  dis- 


Fig.  169. — Eeplacement  of  Retroverted  Uterus  by  two  Fingers  of  Right  Hand,  with  Patient  in  the  Left 
Latere  abdominal  Posiiion.     First  step  (P.  F.  M.). 

placed  fundus  uteri,  as  any  one  can  easily  satisfy  himself  by  trial,  and  I  have 
repeatedly  succeeded  in  raising  the  impacted  fundus  out  of  the  sacral  ex- 
cavation by  the  fingers  of  the  left  hand,  when  the  right  had  failed.  But 
the  backward  traction  of  the  cervix  with  the  left  index  is  not  so  easy,  and 
all  in  all,  I  prefer  the  right  hand  for  the  operation.  Of  course  the  patient 
may  be  placed  on  her  right  side,  if  the  operator  prefers,  and  the  left  hand 
be  then  used,  as  described  for  the  right. 


Fig.  170.— Eeplacement  of  Retroverted  Uterus,  by  Right  Hand,  Patient  on  Left  Side.      Second 

step  (P.  F.  M.). 

Often  it  is  impossible  to  replace  the  utenis  in  this  way,  the  fundus 
being  adherent,  or  the  broad  ligaments  thickened,  or  the  cervix  short. 
The  uterus  will  then  remain  retro-curved,  or  straight,  and  must  be  entirely 


334 


MINOR    GYNECOLOGICAL    MANIPULATIONS. 


anteverted  in  the  knee-chest  position,  or  by  pressure  through  the  rectum, 
or  by  instruments. 

If  sufficient  purchase  is  not  obtainable  on  the  fundus  through  the  va- 
gina, the  two  fingers  of  the  right  hand  may  be  introduced  into  the  rectum 
and  pressui'e  exerted  on  the  fundus  from  that  passage  ;  or,  what  may  per- 
haps be  more  convenient  now,  the  operator  stands  directly  at  the  feet  of 
the  patient  and  inserts  the  first  two  fingers  of  his  left  hand  into  the  rectum, 
the  palmar  surface  of  which  now  jDresses  against  the  anterior  wall  of  that 
canal  and  exerts  a  well-directed  and  systematic  pressure  on  the  fundus. 
The  thumb  of  the  same  hand  meanwhile  enters  the  vagina  and  draws  the 
cervix  backward.  This  method,  of  all  the  manual  devices,  is  the  most 
efficient. 

A  fundus  which  cannot  be  replaced  by  either  of  these  maneuvres  must 
be  firmly  incarcerated  below  the  sacral  promontory,  or  too  tender  to  per- 


FlG.  171.— Replacement  of  Retroverted  Uterus,  by  Right  Hand,  Patient  on  Left  Side.      Third 

step   (P.  P.  M.j. 

mit  effectual  pressure  ;  or  it  is  adherent  to  the  anterior  wall  of  the  rectum. 
This  often  happens  in  old  displacements,  when  the  utero  recto-sacral  liga- 
ments have  become  shortened  by  inflammatory  contraction  or  disease  ;  or 
the  uterus  is  sharply  retroflexed  and  very  flabby  ;  or  the  body  is  much  en- 
larged, as  in  early  pregnancy  ;  or  there  has  been  pelvic  peritonitis.  A  con- 
dition closely  simulating,  and  doubtless  often  taken  for,  adhesion  is  impac- 
tion of  the  fundus  uteri  between  the  contracted  utero-sacral  ligaments, 
•which  can  be  felt  grasping  the  organ  on  either  side.  Steady  pressure  will 
usually,  after  a  time,  overcome  this  resistance  and  permit  the  elevation  of 
the  fundus. 

If  this  vaginal  and  rectal  pressure  fails,  the  attempt  may  be  made  to  re- 
place the  uterus  in  the  knee-chest  position.  The  two  first  fingers  are 
passed  behind  the  ceiwix,  and  the  fundus  is  alternately  pressed  forward 
and  downward,  and  the  cervix  pushed  backward.  The  elongation  of  the 
vagina  in  this  position  somewhat  interferes  with  this  maneuvre,  and  a 
sponge  on  a  long  holder,  or  a  vaginal  depressor,  may  be  employed  to  push 


EEPQSITIOIS"    OF    DISPLACED    UTERUS    AISTD    OVAEIES.         335 

up  the  fundus  in  place  of  the  fingers.  The  most  powerful  replacing  force 
is  exerted  by  the  lingers  or  sponge-probaug  in  the  rectum,  the  thumb,  if 
possible,  drawing  back  the  cervix.  A  uterus  which  resists  this  pressilre 
will  probably  require  the  most  forcible  instrumental  measures  for  its  re- 
placement. 

I  have  generally  been  able  to  replace  a  retroversion  or  retroflexion  by 
the  fingers,  per  vaginam  or  rectum,  in  the  semi-prone  position,  as  above 
described.  Some  operators  prefer  the  knee-breast  position  for  all  cases  ; 
and  no  doubt  the  assistance  of  gravitation,  to  which  may  be  added  that 
of  atmospheric  pressure  when  the  vagina  is  opened,  is  of  great  advantage 
in  effecting  reduction.  When  the  fundus  is  too  firmly  impacted  or  too 
tender  for  replacement  on  the  side,  I  alwaj's  employ  the  knee-breast  posi- 
tion and  atmospheric  pressure  before  resorting  to  further  manual  efforts. 

The  frequent  replacement  of  a  dislocated  uterus  is  in  itself  a  valuable 
method  of  gradual  cure  by  restoring  tone  to  the  ligaments,  and  giving  the 
vagina  the  proper  shape  for  a  supporter. 

A  prolapsed  uterus  is  easily  replaced  by  putting  the  patient  in  the 
dorsal  recumbent  position,  and  pressing  uj)  the  organ  with  one  or  more 
fingers,  if  it  be  descensus  of  the  first  or  second  degree  (not  beyond  the 
vulva),  and  with  the  whole  hand  or  both  hands,  if  of  the  third  degree 
(complete  prolapsus).  If  the  whole  uterus  is  outside  of  the  vulva,  the 
vaginal  walls  being  inverted  with  it,  the  procedure  is  as  follows  :  The  pro- 
lapsed mass  is  well  oiled  or  greased,  and  the  lower  portion  of  the  cone 
grasped  in  the  tips  of  all  the  fingers  of  one  hand,  and  gently  and  gradually 
pressed  upward  until  the  cervix  is  within  the  vulva  and  the  whole  vagina 
has  been  reinverted.  If  the  organ  is  very  turgid,  it  should  be  gTasped  in 
the  whole  of  both  hands  and  gently  compressed,  so  as  to  squeeze  the 
blood  out  of  it,  before  attempting  to  return  it.  Or  cold-water  applications 
may  be  made  to  it  until  it  shrinks  and  its  surface  wrinkles.  A  uterus 
which  in  its  prolapsed  condition  measures  five  or  six  inches  in  length  will, 
on  replacement,  be  found  to  have  contracted  to  three  or  four  inches  ;  this 
phenomenon  is  due  to  a  peculiar  (histologically,  as  yet  unexplained)  putty- 
like ductility  of  the  cervix.  Frequently  the  uterus,  when  replaced,  is  found 
to  be  retroflexed  below  the  promontory,  retroversion  being  the  natural 
precursor  and  companion  of  prolapsus. 

Should  a  prolapsed  uterus  resist  rej^lacement  in  the  dorsal  position, 
the  knee-chest  posture  should  at  once  be  assumed,  and  the  effort  repeated, 
when  no  doubt  it  will  be  successful.  I  have  met  with  no  case  in  which  I 
found  it  necessary  to  use  more  than  the  simple  means  related. 

I  shall  describe  the  replacement  of  an  inverted  uterus  by  manual  and 
instrumental  measures  in  the  same  section  later  on. 

By  Gravitation  and  Atmospheric  Pressure.  * 

A  displaced  uterus,  if  movable  and  not  fixed  by  adhesions,  may,  under 
favorable  circumstances,  be  entirely  replaced  by  gravitation  and  atmos- 
pheric pressure  without  the  aid  of  manual  efforts.  This  applies  both  to 
ante-  and  retro-displacements,  and  to  the  two  first  degrees  of  prolapsus. 


336 


MmOR    GYNECOLOGICAL    MANIPULATIONS. 


If  "u-e  wish  to  replace  an  anteverted  or  anteflexed  uterus  by  these 
means,  it  will  be  necessary  for  us  to  put  the  patient  in  a  position  in  which 
gravitation  will  take  place  away  from  the  pelvis  toward  the  diaphragm,  and 
intra-abdominal  pressure  tow^ard  the  pelvis  will  be  decreased.  This  is 
obtained  b}^  elevating  the  patient's  hips  and  lea%ang  her  head  and  shoul- 
ders on  the  couch  ;  in  proportion  to  the  elevation  of  the  hips  will  the 
effect  be  increased.  Dr.  Yerrier,  of  France,  has  recently  rej)orted  a  con- 
trivance of  his  for  the  systematic  replacement  of  ante-displaced  uteri  by 
gravitation  and  posture,  which  consists  of  two  rope  ladders,  upon  the 
rounds  of  which  the  patient  places  her  feet,  ascending,  until  the  proper 
elevation  for  relaxation  of  the  abdominal  wall  is  found,  while  her  trunk 
occuj)ies  a  recumbent  position  on  the  floor.  The  hi^DS  are  suj)ported  *by  a 
cushion.  In  this  position  the  intestines  glide  in  front  of  the  uterus  and 
the  anteversion  is  replaced.  By  exercising  the  pelveo-abdominal  muscles 
through  lifting  herself  up  by  a  pair  of  elastic  hand  pulleys,  also  attached . 


Fig.  172. — Knee-chest  Position,  showing  Displacement  of  Uterus  and  Intestines  ;  Vagina  Closed 

(CampbeU). 

to  the  ceiling,  the  circulation  is  stimulated.     Daily  sittings  will  ultimately 
result  in  permanent  replacement,  the  author  says. 

With  us  it  is  not  found  necessary  to  resoi-t  to  posture  to  replace  an 
anteverted  uterus.  The  knee-breast  posture  certainly  would  not  answer, 
as  it  would  only  aggravate  the  anteversion.  The  genu-pectoral  position 
is  chiefly  employed  for  the  replacement  of  a  retroverted  uterus,  and  its  de- 
veloj^ment  into  a  systematic  method,  Avith  the  assistance  of  pneumatic 
intra-vaginal  pressure,  is  due  mainly  to  the  efforts  of  Dr.  Henry  F.  Camp- 
bell, of  Augusta,  Ga.  Others  indej)endently  hit  upon  the  same  jDrinciiDle, 
as  So]ger,  of  Berlin,  and  myself  (who  in  my  office  accidentally  replaced  a 
retroverted  gi-avid  uterus  which  had  resisted  all  the  methods  above  men- 
tioned, by  elevating  the  perineum  with  Sims'  speculum  in  the  knee-chest 
position,  and  thus  expanding  the  vagina  with  air),  but  to  Campbell  is  due 
the  credit  of  having  thoroughly  worked  up  the  subject.  His  explanation 
of  the  method  of  replacement  is  illustrated  by  Figs.  172  and  173,  taken 
from  his  article.  In  Fig.  172  the  uterus  is  retroverted,  and  the  intestines 
are  crowded  down  into  the  pelvic  cavity,  learing  a  free  space  between  the 
u^Dper  border  of  the  intestines  and  the  diaphi-agm.     This  vacuum  is,  of 


REPOSITION    OF    DISPLACED    UTERUS    AIS^D    OVARIES. 


337 


course,  imaginary,  and  exists  only  momentarily  while  the  instantaneous 
change  represented  in  Fig.  173  takes  place.  Here  we  see  the  intestines 
all  prolapsed  toward  the  diaphragm,  the  vagina  dilated  (I  have  added  a 
Sims'  speculum  to  show  the  elevation  of  the  perineum)  and  the  uterus  re- 
placed, that  is,  anteverted.  The  forces  which  achieved  this  result  are — 1, 
suspension  of  intra-abdominal  pressure,  and  consequent  traction  on  the 
pelvic  viscera,  vis  afronte,  and  2,  intra-vaginal  atmospheric  pressure,  vis  a 
tergo.  The  former  action  is  a  suction  force  on  the  pelvic  organs,  which  is 
compensated  for  by  the  rush  of  air  into  the  vagina.  The  position  alone 
might  effect  the  replacement,  but  it  is  materially  aided  by  the  air-pressure, 
which  acts  in  the  same  manner  as  the  fingers  in  lifting  up  the  fundus. 

That  all  retro-displacements  can  be  replaced  in  this  manner,  as  Camp- 
bell claims,  has  certainly  not  been  my  experience.  I  have  found  numer- 
ous instances  in  which  the  fundus  remained  wedged  into  the  sacral  ex- 


FlG.  173.— Eepla cement  of  Retroverted  Uterus  in  Knee-chest  Position  and  by  Air-pressure  (Campbell). 


cavation,  no  matter  how  forcibly  the  perineum  was  elevated  and  the  vagina 
expanded.  The  slight  impulse  given  to  the  fundus  by  the  finger  or  de- 
pressor, however,  sufiiced  to  dislodge  it  and  to  bring  the  two  natui'al 
forces  into  play.  Or  the  fundus  might  be  dislodged  by  seizing  the  cervix 
with  a  tenaculum  and  carrying  it  backward  toward  the  sacrum.  This 
manipulation  of  the  cervix  also  answers  a  good  purpose  in  the  lateral  posi- 
tion, when  the  fingers  do  not  readily  succeed  in  elevating  the  fundus. 

The  heavier  the  body  of  the  uterus  is,  the  more  readily  will  it  be 
replaced  in  the  knee-breast  position,  hence  the  special  utility  of  this  posi- 
tion in  retroversion  of  the  gravid  uterus. 

When  the  displaced  fundus  refuses  to  become  dislodged,  a  very  ef- 
fectual and  comparatively  painless  auxiliary  consists  in  a  rubber  bag 
(Barnes'  or  Braun's)  inserted  into  the  rectum  until  it  touches  the  uterus 
and  then  inflated  or  filled  with  warm  water.  When  the  fundus  has  been 
sufficiently  raised  the  bag  is  removed^  and  the  distention  of  the  vagina,  or 
22 


338  MINOR    GYISTECOLOGICAL    MAlSTIPULATIOlSrS. 

what  is  often  more  effectual  still,  that  of  the  rectum,  with  air,  will  usually 
complete  the  reposition. 

Dr.  Campbell  recommends  the  frequent  employment  of  the  genu-pec- 
toral  j)osition  and  air-pressure  by  the  patients  themselves  at  their  homes, 
and  obtains  the  admission  of  air  into  the  vagina  by  teaching  the  patients 
how  to  separate  the  labia  with  the  fingers  when  they  have  assumed  the 
position,  or  by  means  of  a  small  tube,  like  a  leech  or  test-tube,  open  at 
both  ends,  which  the  patient  inserts  into  her  vagina.  After  remaining  in 
this  position  for  some  minutes  the  patient  turns  on  her  side  and  remains 
in  the  latero-abdominal  position  for  some  time,  a  few  hours  or  longer.  In 
order  to  prolong  the  replacement  of  the  uterus  and  relaxation  of  the  pel- 
vic hgaments  as  much  as  possible,  Campbell  advises  that  this  method 
should  be  practised  every  evening  on  retiring,  the  patient  remaining  in 
the  side  position  during  the  remainder  of  the  night.  In  this  wa}^  he 
claims,  the  ligaments  gradually  regain  their  tone,  and  in  course  of  time  a 
ciu'e  may  be  obtained.  The  facihty  of  this  practice  recommends  it  very 
highly.  I  have  been  in  the  habit  for  several  yeai*s  of  directing  my  patients 
with  retro-displacements  to  assume  the  genu-pectoral  position  and  sepa- 
rate the  labia  several  times  a  day,  and  have  certainly  heard  good  reports 
as  regards  relief  from  backache  and  beai'ing  down  from  it.  The  fitting  of 
a  pessary  is  also  facilitated  by  this  frequent  reposition  of  the  uterus  and 
expansion  of  the  vagina  ;  and  a  slightly  displaced  pessary  may  be  spon- 
taneously replaced,  and  the  pressure  on  the  posterior  wall  of  the  uterus 
and  the  retro-uterine  tissues  by  the  pessary  relieved  by  daily  employment 
of  the  same  method. 

By  Instruments. 

When  a  displaced  uterus  cannot  be  lifted  ujo  and  straightened  by  the 
measures  above  described,  the  replacement  may,  if  it  be  imperative,  be 
accomphshed  by  means  of  instruments. 

It  should  be  distinctly  understood,  however,  that  the  difficulty  is  prob- 
ably due  to  adhesions,  and  that  such  a  replacement,  after  the  ordinary- 
means  fail,  is  justifiable  only  by  the  severity  of  the  symptoms,  and  sliould 
be  looked  upon  as  an  operation.  This  holds  good  for  those  cases  in  which 
the  fundus  is  unquestionably  adherent,  and  in  which  a  rekindling  of  the 
affection  which  caused  the  adhesions,  viz.,  a  pelvic  peritonitis,  is  greatly 
to  be  feared.  But  there  are  numerous  cases  where  the  uterus  is  so  much 
flexed,  or  so  heav}-,  or  so  flabby,  or  the  fundus  is  impacted  between  the 
utero-sacral  ligaments  (chiefly  retroflexion  and  retroversion),  or  where  it  is 
desii'ed  to  cai'ry  it  into  the  opposite  displacement,  that  the  fingers  and 
position  alone  are  unable  to  accomplish  the  reposition.  Here,  adhesions 
and  other  counter-indications  to  the  use  of  intra-uterine  instruments  being 
absent,  the  replacement  by  means  of  a  sound  or  instrument  sj^ecially  con- 
structed for  the  purpose,  is  no  very  serious  matter,  if  gently  and  carefuUy 
performed. 

The  uterus  can  be  replaced  by  gently  passing  the  sound  in  the  dii-ec- 


REPOSITIOlSr    OF    DISPLACED    UTERUS    AND    OVAKIES, 


339 


tion  of  the  curve  of  the  uterine  canal  (in  ante-displacement  with  concavity 
forward,  in  retro-displacement  Avith  concavity  backward — see  Figs.  166  and 
167),  up  to  the  fundus,  and  then  very  gently  rotating  the  sound  until  its 
concavity  points  in  the  opposite  direction.  In  this  movement  the  rotation 
should  be  chiefly  with  the  handle  of  the  sound,  the  point  is  merely  turned . 
on  its  own  axis,  describing  but  a  very  slight  curve  and  thus  exerting  almost 
no  force  on  the  endometrium.  The  curve  of  the  uterine  canal  has  now 
been  reversed,  but  the  uterus  itself  is  not  entirely  rejDlaced.  This  is  done 
by  depressing  the  handle  of  the  sound  gently  until  it  touches  the  perineum, 
in  retroversion,  and  by  elevating  it  to  the  symphysis  in  anteversion.  The 
fundus  will  then  always  be  carried  in  precisely  the  opposite  direction  from 
the  handle. 

Frequently  this  maneuvre  is  less  painful  and  difficult  than  the  manual 
reposition  of  a  tender,  congested,  retroverted,  or  shai-ply  retroflexed  ute- 
rus. If  gently  done,  it  need  give  no,  or  but  httle,  pain,  and  produce  no 
reaction,  perhaps  merely  the  discharge  of  a  few  drops  of  blood. 


Jennison's  Uterine  Sound  and  Repositor. 


I  have  frequently  employed  the  ordinary  Simpson  sound,  and  have 
never  met  with  the  slightest  evil  result.  But,  when  the  uterine  canal  is  suf- 
ficiently patent,  I  should  certainly  advise  a  thicker  sound,  such  as  Peaslee's 
(Fig.  60)  ;  or  a  sound  with  a  circular  plate  at  about  two  and  one-fourth 
inches  from  the  tip  might  be  used,  upon  which  plate  the  cervix  rests 
and  which  prevents  the  point  from  touching  the  fundus.  An  injury  to 
the  fundus  can  be  pi'oduced  only  by  gross  violence  or  in  a  diseased  uterus. 

The  force  used  in  this  maneuvre  is  gauged  entirely  by  the  touch  of  the 
operator,  and  upon  his  skill  and  caution  depends  the  avoidance  of  injury. 
In  order  to  prevent  this  variable  force,  special  instruments  for  reposition 
have  been  contrived,  which  replace  the  uterus  either  by  gradual  action 
through  a  screw-mechanism,  or  rapidly  by  a  hinge-process.  An  instni- 
ment  of  the  former  variety  is  that  of  Elliot,  which  is  introduced  cm-ved 
and  straightened  by  the  screw  in  the  handle,  if  it  is  desired  to  merely 
straighten  a  flexion,  or  introduced  straight  and  then  curved  in  the  re- 
spective direction,  if  an  anteversion  is  to  be  converted  into  a  retroversion, 
or  the  reverse. 

A  very  ingenious  sound  and  repositor  is  that  of  Jennison,  shown  in 
Fig.  174.     It  is  made  of  steel  spirals  so  jointed  that  when  the  lower  end 


840  MINOR    GYNECOLOGICAL    MAjSTIPULATIONS. 

of  the  sound  is  pressed  down  the  tipper  end  turns  upward  in  proportion, 
and  vice  versa.  It  can  thus  he  made  to  enter  a  flexed  uterus  very  easily, 
and  the  handle  being  then  pressed  in  the  ojDposite  direction  the  uterus  is 
reversed,  entirely  in  proportion  to  the  amount  of  curvature  of  the  handle. 
Instruments  of  the  second  class  are  the  repositors  of  Emmet  and  Sims, 
the  former  of  which  is  shown  in  Fig.  175.  The  difference  between  them  is 
only  that  the  stem  of  Emmet's  is  jointed  so  as  to  admit  of  its  easy  passage 
through  a  flexed  canal,  while  that  of  Sims  is  in  one  straight  piece.  The 
stem  is  so  attached  by  a  hinge  to  the  shank  of  the  insti'ument,  that  when 
the  point  is  near  the  fundus,  as  shown  by  the  broad  plate  touching  the 
cervix,  by  a  rotation  of  the  stem  within  the  uterus  and  the  pushing  of  the 
instrument  into  the  anterior  or  posterior  vaginal  pouch  (anterior,  if  an 
anteflexed  uterus  is  to  be  retroflexed  ;  posterior,  if  a  retroflexed  uterus  is 
to  1)6  anteflexed)  the  fundus  will  be  raised  and  carried  in  the  opposite 
direction.  It  is  necessary  to  turn  the  instrument,  if  Emmet's  is  used,  in 
order  to  bring  the  inside  of  the  hinges  toward  the  direction  to  which  the 
uterus  is  to  be  carried.  This  rotation  is  an  objection  to  Emmet's  reposi- 
tor,  because  the  endometrium  is  easily  lacerated  by  the  joints.  In  this 
respect  that  of  Sims  is  preferable,  but  the  latter  is  difficult  to  pass  through 


■^^^SCWNAOT. 


Fig.  175.— Kmmet's  Uterine  Repositor. 


a  sharp  flexion.  I  formerly  used  these  repositors  quite  often,  but  of  late 
years  have  succeeded  quite  as  well  with  the  thick  sound  in  the  compara- 
tively few  cases  in  which  forcible  instrumental  reposition  was  required. 

These  instruments  may  all  be  used  in  the  dorsal  position  without  the 
aid  of  a  speculum,  being  introduced  according  to  the  rules  given  for  the 
ordinary  sound,  or  they  may  be  inserted  in  the  semiprone  position  through 
a  Sims  sjDeculum.  If  the  latter,  the  cervix  should  be  seized  with  a  tenacu- 
lum, and  the  uterus  drawn  down  and  straightened  as  much  as  possible, 
before  the  repositor  is  introduced.  "NYlien  the  rej)lacement  is  about  to  be 
effected,  the  operator  should,  with  his  left  hand,  seize  the  speculum  from 
the  nurse,  she  still  lifting  the  superior  labium,  and  gently  follow  with 
the  point  of  the  specukuu  the  direction  given  to  the  fundus  until  its  posi- 
tion is  reversed.  By  so  doing  the  fixation  of  the  uterus  by  the  backward 
traction  of  the  speculum  is  temporarily  suspended,  and  undue  force  avoided. 
When  the  organ  is  replaced,  the  speculum  is  handed  back  to  the  nurse. 
This  rule  applies  chiefly  to  retro-displacement. 

It  Avill  be  stated  in  the  proper  place  that  a  displaced  uterus  should 
always  be  restored  to  its  normal  position  before  a  pessary  is  applied.  This 
replacement  should  be,  if  possible,  and  in  the  large  majoiity  of  cases  can 
be,  effected  by  one  of  the  non-instrumental  methods  described,  chiefly  that 
with  two  fingers  in  the  left  latero-abdominal  position,  which  I  have  found 


EEPOSITION    OF    DISPLACED    UTERUS    AND    OVARIES.         341 

the  best  method.  The  practice  of  some  gynecologists  to  elevate  the  uterus 
with  the  sound,  and  then  pass  the  pessary  into  position  over  the  sound,  is 
decidedly  reprehensible  and  unnecessary.  A  uterus  should  never  be  re- 
placed by  an.  instrument  until  repeated  manual  and  postural  attempts  have 
failed.  In  order  to  ensure  retention  of  the  replaced  organ  until  a  pessary 
can  be  applied  for  permanent  support,  a  position  should  be  maintained  in 
which  gravitation  favors  such  retention  :  in  ante-displacement  with  elevated 
hips,  in  retro-displacement  and  prolapsus,  the  latero  abdominal  or  genu- 
pectoral  positions. 

I  wish  to  particularly  impress  the  axiom,  that  instrumental,  forcible, 
reposition  of  a  displaced  uterus  is  justifiable  after  the  non-instrumental 
methods  fail  only  when  the  dangers  possibly  arising  from  such  forcible 
reposition  are  clearly  understood,  and  the  symptoms  call  for  interference. 
Such  cases  are  chiefly  those  of  retro-displacement ;  an  anteverted  uterus 
rarely  becomes  adherent.  Under  certain  circumstances,  when  the  adhe- 
sions are  old  and  lax,  and  the  parametrium  is  not  at  all  tender,  and  when 
the  necessity  for  replacement  is  imperative,  an  attempt  may  be  made  to 
gently,  steadily,  and  forcibly  antevert  the  uterus  with  one  of  the  above 
instruments  ;  this  is  done  with  the  distinct  intention  of  stretching  or  tear- 
ing the  adhesions,  and,  therefore,  with  the  knowledge  of  the  danger  of 
such  a  practice.  This  is  an  oi^eration,  and  should  always  be  performed  at 
the  house  of  the  patient,  under  anesthesia,  and  the  patient  should  be  kejot 
in  bed  for  three  or  four  days  or  longer,  until  all  chance  of  peritonitis  has 
passed. 

Dr.  A.  F.  Erich,  of  Baltimore,  has  recently  operated  on  several  such 
cases  with  success,  using  a  stout  steel  sound  with  a  circumference  of  3G 
mm.  at  its  tip.  The  anterior  wall  of  the  rectum  should  be  held  back  by 
fingers,  or  a  thick  bougie  in  that  passage,  or  else  it  will  be  lifted  up,  and 
the  adhesions  remain  untorn.  I  myself  have  had  one  similar  and  highly 
successful  case.  A  more  gentle,  but  certainly  less  certain  method  is  that 
of  Kuechenmeister,  by  passing  a  rubber  bag  into  the  rectum  and  dis- 
tending it  with  water,  leaving  it  there  as  long  as  the  patient  can  bear  it. 
This  is  to  be  repeated  eveiy  day  until  the  uterus  is  replaced,  or  the  rec- 
tum becomes  too  irritable.  The  exercise  of  force  in  elevating  a  retro- 
verted  and  adherent  uterus  cannot  be  too  severely  deprecated.  Although 
the  replacement  of  such  an  organ  is  to  be  ardently  desired,  the  dangers 
attending  the  operation  have  deterred  the  majority  of  gynecologists  fi'om 
attempting  it.  It  is  to  be  hoped  that  time  will  bring  us  an  efficient  and 
safe  remedy  for  these  inti-actable  cases. 

It  should  be  understood  that  fixation  of  the  uterus  to  a  greater  or  lesser 
degree  by  plastic  exudations  into  and  subsequent  contraction  of  one  or 
both  broad  ligaments,  or  the  parauterine  cellular  tissue,  does  not  belong 
IDroperly  under  the  head  of  the  corporeal  and  fundal  intraperitoneal  ad- 
hesions above  spoken  of.  Cellulitic  fixation  or  displacement  is  not,  as 
a  rule,  amenable  to  forcible  treatment  or  reposition.  Fortunately,  true 
adhesion  of  the  fundus  uteri  is  not  as  common  as  is  generally  assumed  ; 
at  least,  authorities  like  Sims  and  Emmet  claim  to  have  seen  compara- 


342  MINOR    GYISTECOLOGICAL    MANIPULATIOITS. 

tively  few  cases  in  wliicli  the  adhesion  was  unquestionable,  and  believe 
that  a  large  proportion  of  the  instances  reported  as  such  were  merely  cases 
of  impaction  between  the  utero-sacral  ligaments.  While  I  have  frequently 
recognized  the  latter  condition,  I  still  have  in  my  recollection  quite  a 
number  of  cases  in  which  the  body  and  fundus  of  the  uterus  were  un- 
questionably adherent  to  the  posterior  surface  of  Douglas'  pouch ;  the  his- 
tory of  pelvic  inflammation  and  the  physical  conditions  agreed  perfectly. 
In  fact,  I  do  not  see  how  a  case  of  retro-uterine  pelvic  peritonitis  can  pro- 
duce any  other  result  than  adhesion  between  the  two  opposing  surfaces  of 
Douglas'  pouch,  and  that  such  adhesions  are  by  no  means  always  entirely 
absorbed  and  the  uterus  again  set  free,  is  my  conviction.  Winckel,  in  his 
excellent  photohthographic  plates  from  nature,  shows  a  number  of  speci- 
mens of  such  adhesions.  Such  attachments  may  be  gradually  stretched, 
by  frequently  repeated  gradual  elevation  of  the  fundus  uteri,  if  they  are 
not  too  broad  ;  but  I  have  only  once,  as  yet,  dared  to  tear  away  the  uterus 
from  its  broad  adhesion,  and  then  with  complete  success. 

The  replacement  of  the  2^1'olapsed  ovaries  is  easily  effected,  unless  they 
are  adherent,  by  the  manual  and  postural  methods  described  for  retrover- 
sion of  the  uterus.  A  proper  retaining  support  should  be  introduced  be- 
fore the  erect  position  is  resumed,  or  the  ovaries  will  at  once  glide  down 
again,  which,  indeed,  is  too  often  the  case,  even  with  a  pessary. 

The  replacement  of  an  inverted  uterus  may  be  effected  by  manual  and 
instrumental  methods,  both  acting  very  much  in  the  same  manner,  by  ex- 
erting steady  and  continuous  pressure  on  the  inverted  fundus.  The  chief 
difficulty  is  to  overcome  the  resistance  offered  to  the  re-inversion  of  the 
fundus  by  the  firmly  contracted  ring  of  the  cervix.  To  dilate  this  ring 
by  counter-pressure  from  above  is  quite  as  important  as  the  upward  for- 
cing of  the  fundus  from  the  vagina.  All  methods,  therefore,  seek  to  com- 
bine these  two  forces. 

The  methods  are  either  such  as  are  designed  to  effect  rapid  reduction, 
or  such  as  attain  their  object  by  continued  and  gradual  force.  Either 
may  be  accomplished  by  manual  or  by  instrumental  efforts,  or  by  both 
combined. 

Of  the  methods  for  rapid  reduction,  those  of  Emmet,  Barriei",  Noegge- 
rath,  Courty  and  Tate  (manual).  White  and  Byrne  (instrumental),  are  the 
most  practical. 

Emmet's  method  consists  in  grasping  the  whole  uterus  with  the  hand 
in  the  vagina,  and  with  its  palm  forcing  the  fundus  up  while  the  fingers 
endeavor  to  dilate  the  cervical  ring  ;  the  combined  fingers  of  the  other 
hand  meanwhile  exert  steady  counter-pressure  on  the  ring  through  the 
abdominal  wall. 

Barrier  also  grasps  the  uterus  in  the  whole  hand,  and  forces  the  cervix 
up  against  the  sacrum  as  a  point  of  resistance,  while  the  thumb  presses  in 
the  fundus. 

Noeggerath  places  the  index-finger  on  one  horn  of  the  uterus,  the 
thumb  on  the  other,  and  endeavors  to  indent  and  x-e-invert  first  one  corner 
and  then  the  other  ;  this  having  succeeded,  central  pressure  on  the  re- 


EEPOSITION    OF    DISPLACED    UTERUS    AND    OVARIES.         343 

inverted  cup  is  made,  until  reduction  is  completed.  Counter-pressure  is 
exerted  in  the  usual  way  by  the  outer  hand.  This  is  an  excellent  method, 
and  has  achieved  more  results,  probably,  than  any  other.  Thomas  reports 
succeeding  with  it  in  three  out  of  five  cases. 

Courty's  method  consists  in  passing  the  index  and  middle  finger  into 
the  rectum,  and  hooking  them  through  the  anterior  rectal  wall  into  the 
cervical  ring  ;  the  thumb  of  the  same  hand  or  the  whole  other  hand  then 
compresses  and  pushes  up  the  fundus,  while  the  two  rectal  fingers  en- 
deavor to  dilate  and  draw  down  the  cervical  ring.  The  advantage  this 
plan  gives,  if  the  ring  can  be  firmly  grasped,  is  apparent.  A  modification, 
and  in  point  of  efficiency,  doubtless,  an  improvement  is  the  method  of  J. 
H.  Tate,  of  Cincinnati,  who  dilated  the  urethra,  and  introduced  the  index- 
finger  of  the  left  hand  through  the  bladder  into  the  cer\dcal  ring,  and  two 


Fig.  176. — Tate's  Method  of  Reduction  of  an  Inverted  TJtorus.     Diagrammatical  (P.  F.  M.). 

fingers  of  the  right  hand  through  the  rectum  also  into  the  ring,  and  both 
thumbs  against  the  cornua  of  the  fundus  in  the  vagina.  By  now  dilating 
the  cervical  ring  with  the  fingers  of  both  hands,  while  the  thumbs  push  up 
the  fundus,  the  reduction  of  the  inversion  was  inevitable.  I  am  not  aware 
whether  any  one  but  the  inventor  has  used  this  method  ;  he  succeeded 
with  it  admirably  in  a  case  of  forty  years'  standing  after  but  half  an  hour's 
efforts  {Cincinnati  Lancet  and  Observer,  March,  1878),  completing  the  re- 
duction by  pushing  up  the  fundus  with  a  tallow-candle  wrapped  in  a  rag. 
To  prevent  return  of  the  inversion,  the  external  os  was  closed  by  a  silver 
suture,  which  was  removed  on  the  third  day.  The  patient  recovered  with- 
out any  untoward  symptom. 

Theoretically,  this  plan  would  seem  by  far  the  most  efficient  of  any. 
The  disadvantage  of  dilating  the  urethra  carries  but  little  weight,  com- 
pared with  the  great  benefit  to  be  derived  from  the  double  fixation  of  the 


344  MINOE    GYNAECOLOGICAL    MANIPULATIONS. 

cervical  ring.  Besides,  every  patient  whose  inverted  ufceiais  is  to  be  re- 
duced is  eo  ipso  put  under  an  anesthetic  ;  the  urethral  dilatation,  therefore, 
requires  no  previous  preparation. 

"White's  method  consists  in  pushing  up  the  fundus  with  a  hard  rubber 
cup  attached  to  a  stem  and  strong  spiral  spring  which  is  pressed  against 
the  thorax  of  the  operator,  the  vaginal  hand  steadying  the  cup  while  the 
outer  hand  exercises  the  usual  counter-pressure  and  dilatation  of  tlie  ring. 

Byrne's  instrument  consists  of  a  hard-rubber  cuj)  to  fit  over  the  fun- 
dus (of  which  there  are  three  sizes),  the  largest  two  and  one-half  inches 
in  diameter,  in  which  a  movable  plate  is  fixed  which  can  be  slowly  pro- 
pelled forward  by  a  screw  in  the  handle.  Another  similar  cup  with  a  mov- 
able cone  is  placed  on  the  abdomen  over  the  cervical  ring,  and  the  cone 
advanced  by  means  of  a  screw  until  it  enters  the  ring.  By  now  slowly 
screwing  forward  the  plate  in  the  vaginal  cup,  and  exerting  counter- 
pressure  with  the  cup  and  cone  on  the  abdomen,  the  fundus  was  entirely 
replaced  in  three  stages  within  half  an  hour,  in  a  case  of  inversion  of 
nine  days'  standing  which  had  X'esisted  previous  efforts  at  replacement. 
Thomas  rejDorts  having  emploj-ed  the  instrument  successfully  in  one  case. 

The  time  required  to  replace  a  uterus  by  these  rapid  methods,  may 
vary  from  a  few  miniites  to  several  hours,  if  unsuccessful  sooner,  until  in 
fact  the  operator  is  exhausted,  or  regard  for  the  consequences  to  the 
patient  of  such  long-continued  force,  and  the  length  of  the  anesthesia,  call 
for  a  postponement  of  the  reduction  to  another  day.  Anesthesia  is  re- 
quired in  every  case,  both  to  relieve  the  unavoidable  pain  and  to  relax  the 
tissues.  The  operator  should  have  several  trained  assistants  to  reheve 
him  when  his  strength  gives  out,  as  it  often  will ;  both  hands  should  be 
employed  alternately.  The  uterus  should  have  been  softened  by  frequent 
hot  vaginal  baths  for  some  time  before  the  operation.  If  one  attempt 
does  not  succeed,  the  patient  should  be  jDut  to  bed,  and  all  jDrecautions 
adopted  to  prevent  peritonitis  ;  and  when  this  danger  has  subsided,  a 
fresh  attempt  should  be  made,  and  so  on  until  the  reduction  is  effected,  or 
its  impossibility  assured  by  any  rapid  method.  Then,  one  of  the  means 
of  gradual  reduction  should  be  employed,  or  if  this  fails,  amputation  may 
be  called  for.  As  a  substitute  for  this  last  resort,  Thomas  has  practised 
an  operation  which  rationally  is  perfectly  correct,  but  the  boldness  of 
which  has  prevented  its  being  followed.  He  opened  the  abdominal  cavity 
and  with  an  instrument  like  a  glove-stretcher  dilated  the  cervical  ring, 
while  the  other  hand  in  the  vagina  pushed  up  the  fundus.  One  patient 
recovered,  the  other  died.  In  view  of  the  recent  favorable  reports  of  ab- 
lation of  the  inverted  uterus  by  the  elastic  ligature,  completed  by  the  knife, 
it  seems  scarcely  likely  that  Thomas'  method  will  find  many  followers. 

The  dangers  from  these  manipulations  are  by  no  means  inconsiderable. 
Peritonitis  or  cellulitis  may  follow  the  necessarily  forcible  handling  of  the 
uterus  and  adnexa,  and  these  affections  may  terminate  fatally  or  result  in 
adhesions  between  the  opposing  uterine  surfaces  or  fixation  of  the  organ 
in  its  inverted  position  and  consequent  permanent  impracticability  of  re- 
duction. 


EEPOSITION    OF    DISPLACED    UTERUS    AND    OTARIES.  845 

When  the  reaction  following  efforts  at  rapid  reduction  gives  rise  to  fears 
of  such  results,  or  when  all  forcible  methods  fail,  the  influence  of  gradual 
pressure  against  the  fundus  should  be  tested.  The  methods  by  which  this 
may  be  performed  are  :  elastic  pressure  by  vaginal  stem,  and  cup  or  bulb  ; 
elastic  pressure  by  vaginal  water-bag  combined  with  taxis,  or  by  vaginal 
bag  alone. 

In  the  first  method  a  cup  (like  that  of  White's  or  Byrne's  repositors), 
or  an  olive-shaped  bulb  of  hard  rubber  or  wood,  is  introduced  into  the 
vagina  and  placed  over  or  against  the  inverted  fundus  ;  the  stem  is  at- 
tached to  a  broad  elastic  belt,  which  passes  between  the  thighs  and  is  fast- 
ened before  and  behind  by  buckles,  to  a  firm  abdominal  belt.  By  tight- 
ening this  strap  the  pressure  may  be  increased  at  will.  Or  the  broad 
T-band  may  be  replaced  by  four  strong  cords  of  elastic  tubing  or  solid 
elastic,  which  pass  up  in  front  and  behind,  and  are  attached  to  the  abdom- 
inal belt  at  either  side  of  the  median  line.  Counter-pressure  should  be 
exerted  by  a  tight  roll  of  cotton  several  inches  in  diameter,  which  is 
placed  across  the  hypogastrium,  immediately  above  the  symphysis  and 
kept  there  by  a  broad  strip  of  adhesive  j^laster  passed  entirely  around  the 
body.  To  prevent  the  uterus  from  slipping  to  one  side  under  the  steady 
pressure  of  the  cup,  it  is  well  to  pack  the  vaginal  vault  around  the  uterus 
with  carbolized  cotton,  before  applying  the  cup.  The  pressure  of  the  cup 
or  bulb  should  be  only  very  gradually  increased,  if  at  all.  Steady,  firm, 
gentle  pressure  against  the  fundus  will  tire  out  the  contracted  uterus 
more  effectually  than  too  much  force. 

Eeduction  by  the  gradual  pressure  of  an  elastic  bag  in  the  vagina  is 
quite  as  sure  a  method  as  the  above.  If  desired,  the  gradual  pressure 
may  be  combined  Avith  dail}'  kneading  of  the  uterus  with  the  hand.  But 
the  bag  alone  will  often  suffice.  After  packing  the  vaginal  pouch  with 
carbolized  glycerated  cotton,  the  bag  is  introduced,  and  filled  with  water. 
Thomas  recommends  retaining  the  bag  by  a  broad  strip  of  adhesive  plaster 
which  is  attached  to  the  abdominal  waU  near  the  navel  in  fi'ont,  and  to 
the  lumbar  region  behind.  Two  holes  are  cut  in  it  for  the  passage  of  ruine 
and  the  tube  of  the  bag.  The  latter  may  be  still  more  distended,  or  re- 
laxed, as  the  indication  occurs. 

An  excellent  method  is  that  of  Wing,  who  places  against  the  inverted 
fundus  a  thick  rubber  ring  (like  a  circular  soft  rubber  pessary)  and  in  this 
a  rounded  poHshed  plug  of  wood  about  one  and  a  half  to  two  inches  in 
diameter  ;  to  the  external  end  of  this  plug  are  attached  foiu*  pieces  of 
stout  rubber  tubing  or  cord  crossing  each  other,  which  pass  anteriorly  and 
posteriorly  betw^een  the  thighs  and  are  fastened  to  a  broad  belt  around  the 
w^aist.  The  rubber  ring  prevents  the  plug  from  slipping  from  the  fundus, 
and  the  rubber  cords  exert  steady  elastic  pressure  inward  and  upward, 
and  can  be  shortened  at  wiU.  AYing  reports  several  cases  of  old  inversion 
reduced  within  twenty-four  to  forty-eight  horu'S  by  this  method,  which  dif- 
fers essentially  from  that  described  above,  in  the  ring  whereby  the  plug  is 
prevented  from  slipping. 

It  is  not  necessary,  nor  indeed  feasible,  to  anesthetize  the  patient  dur- 


346  MIlSrOR    GYNECOLOGICAL    MANIPULATIOJS^S. 

ing  this  trial  of  gradual  pressure,  because  the  pain  is  usually  not  very  great 
if  the  ]Dressure  is  but  slight,  and  because  the  treatment  lasts  too  long.  In 
one  case  gradual  pressure  was  exerted  for  eighteen  days  before  the  re- 
duction was  comj^leted.  The  Umit  of  trial  of  this  method,  therefore,  de- 
pends entirely  upon  the  endurance  of  the  patient.  It  certainly  is  far  safer 
than  rapid  reduction.  Occasionally,  the  patient  cannot  endure  the  wear- 
ing, stretching  pain  of  the  dilated  bags,  or  repositors,  or  inflammatory 
symptoms  begin  to  show  themselves,  and  then  anesthesia  and  rapid  reduc- 
tion are  called  for. 

Two  other  methods  have  been  recommended,  which  act  on  a  different 
principle  from  those  described  :  that  by  repeated  bathing  of  the  uterus 
with  cold  water  thrown  forcibly  into  the  A'^agina  with  a  syringe  through  a 
speculum  (one  case  of  success  is  reported  by  Martin,  of  France),  and  that 
of  Thomas,  by  encircling  the  uterus  with  a  bandage  of  rubber  sheeting. 
Both  methods  have  for  their  object  the  compression  and  diminution  in  size 
of  the  uterus,  and  thereby  its  spontaneous  re-inversion.  In  the  one  case 
in  which  Thomas'  method  was  tried  (a  case  of  Dr.  Eobert  Watts)  the  elas- 
tic pressure  produced  sloughing  of  the  uterine  mucous  membrane  and 
peritonitis,  from  which  the  patient  recovered.  The  rubber  bandage  was 
discarded,  and  the  case  was  finally  cured  by  the  pressure  of  an  elastic  bag. 

The  number  of  cases  of  reduction  of  an  invei'ted  uterus  by  either  one 
of  the  methods  named  has  become  so  numerous  of  late  years  that  an  addi- 
tional case  excites  no  special  attention.  The  oldest  case  of  reduction  is  that 
of  Tate,  forty  years  ;  next  come  those  of  White,  of  Buffalo,  twenty-two  and 
fifteen  years  ;  Noeggerath,  Dibardier,  thirteen  years  ;  Abbie  C.  Tyler, 
eleven  years  ;  and  numerous  others  up  to  within  a  few  months  of  the  oc- 
currence of  the  accident. 

Several  cases  of  spontaneous  reduction  of  the  inversion  are  on  record, 
the  latest  of  which  is  that  of  Spiegelberg.  There  are  nine  others,  those  of 
Leroux,  De  la  Barre,  Baudelocque,  Thatcher  ;  three  of  Meigs ;  Eendu, 
Shaw.  The  mechanism  of  this  process  is  explained  only  in  Spiegelberg'a 
case,  as  follows  :  The  reduction  took  place  during  a  profuse  diarrhea, 
with  straining ;  thereby  the  uterus  was  forced  down  into  the  pelvis,  the 
round  ligaments  were  put  to  their  utmost  tension,  and  the  diarrhea  con- 
tinuing, the  inverted  fundus  was  drawn  up,  and  gradually  replaced  by  the 
traction  of  the  round  ligaments.     This  explanation  certainly  is  plausible. 


XII.      PESSARIES. 

By  pessaries,  we  mean  instruments  of  various  constinictions,  shapes, 
and  materials,  designed  for  the  purpose  of  supporting  a  displaced  or  dis- 
torted uterus  after  its  replacement,  or  of  gradually  effecting  that  replace- 
ment. They  have  been  employed  in  crude  shapes  for  many  years  (the 
Arabians  used  a  distended  animal  bladder  ;  Pare,  in  1573,  made  the  first 
ring-shaped  instrument)  ;  but  only  since  the  invention  of  the  lever  pessary 
by  Dr.  Hugh  L,  Hodge,  of  Philadelphia,  can  it  be  said  that  the  construe- 


ABDOMINAL    SUPPORTERS. 


347 


tion  and  application  of  vaginal  pessaries  has  rested  on  scientific  and  prop- 
erly appreciated  mechanical  principles. 

According  to  the  construction  and  manner  of  use  of  pessaries,  or  ute- 
rine supporters,  as  they  are  also  called,  they  are  divided  into  four  varieties  : 
1,  abdominal ;  2,  vaginal ;  3,  vagino-abdominal ;  4,  intra-uterine. 


1.  Abdominal  Supportees. 

Abdominal  bandages,  corsets,  supporters,  are  used  either  to  sustain  the 
relaxed,  flabby,  pendulous  abdominal  walls  ;  or  to  support  abdominal  tu- 
mors or  the  pregnant  uterus ;  or  to  compress  the  abdominal  walls  after 
removal  of  a  large  mass  from  the  peritoneal  cavity,  as  after  labor,  ovari- 
otomy, tapping  for  ascites  ;  or  to  lift  up  the  fundus  of  an  ante-displaced 
uterus. 

According  to  the  indication,  a  different  form  of  supporter  is  required. 
If  it  is  desired  merely  to  support  the  abdominal  walls  by  a  uniform  press- 
ure exerted  over  the  whole  surface  and  directed  chiefly  upward,  bandages 


Fig.  177. — Pinard's  AbclomiDal  Supporter. 

which  enclose  the  whole  abdomen  are  the  most  serviceable.  They  are 
either  composed  of  silk,  or  elastic  bandages  sewed  together,  and  closed  by 
lace  work  behind,  or  of  silk  or  jean  with  whalebone  rods  at  intei-vals  to  en- 
sure stiffness,  and  composed  of  several  sections  loosely  united,  the  whole 
fastened  by  a  strap  or  laces.  Or  the  thoracic  corset  is  made  to  extend 
down  over  the  abdomen  to  the  pubes,  behig  stiffened  by  whalebones.  Or 
the  bandage  shown  in  Fig.  177,  and  devised  by  Pinard,  of  Paris,  to  retain 
the  fetus  in  its  rectified  position  after  external  version,  will  be  found  ser- 
viceable in  abdominal  tumoi's.  One  of  the  objections  to  all  these  abdominal 
bandages  is  that  they  ai-e  liable  to  slip  up  and  wiinkle,  unless  held  down 
to  the  hips  and  pubes  by  bands  passed  between  the  thighs.  These  bands 
are  either  made  of  leather,  or  cloth,  or,  still  better,  of  I'ubber-tubing  at- 
tached before  and  behind  by  looped  cords.  Most  patients  object  de- 
cidedly to  the  friction  and  pressure  of  these  cords,  and  it  always  takes 


348 


MINOR    GYJSTECOLOGICAL    MANIPULATIONS. 


several  days  for  tliem  to  become  used  to  them.  If  it  is  preferred,  a  broad 
single  central  band  may  be  substituted  for  these  two  lateral  bands.  This 
is  particularly  useful  if  it  is  desired  to  exert  a  supporting  influence  over 
the  vulva,  as  for  the  retention  of  prolapsus,  or  vaginal  pessaries,  or  tam- 
pons, or  hernia  of  the  labium.  The  supporter  of  Noeggerath  is  a  useful 
contrivance  of  this  kind,  the  central  pad  being  attached  to  two  bands  be- 
fore and  behind.  The  portion  fitting  over 
the  vulva  is  generally  occupied  by  a  longi- 
tudinal pad  covered  with  oiled  silk  or  rub- 
ber cloth. 

The  whalebone  rods  usually  inserted  in 
these  supporters  to  render  them  stiff  are 
liable  to  press  into  the  flesh  or  rub  against 
the  crest  of  the  ilium.  They  are  therefore 
often  unbearable,  and  give  so  much  dis- 
comfort as  to  be  discarded,  and  replaced 
by  a  soft  bandage  with  thigh-straps.  A 
woman  can  very  often  manufacture  such  a 
bandage  for  herself  much  better,  and  cer- 
tainly very  much  cheaper,  than  she  can 
buy  it.  Strong  jean,  canton  flannel,  or  un- 
bleached muslin,  can  easily  be  shaped,  with 
a  little  ingenuity,  into  a  bandage  which 
will  fit  closely  to  the  form,  if  supplied  with 
two  broad  elastic  bands  at  the  top  and  bot- 
tom, which  are  long  enough  to  go  entirely 
around  the  body,  and  buckle  in  front.  The 
lower  strap  should  be  fastened  more  tightly 
than  the  upper,  in  order  to  press  the  ab- 
domen upward.  A  practical  home-made 
supporter  appears  to  be  the  one  shown  in 
Fig.  178,  which  is  described  by  Dr.  Julia 
H.  Smith,  of  Chicago.  The  cut  shows  the 
bandage  in  position.  "It  is  made  of  cot- 
ton drilling  for  winter,  heavy  linen  for  summer  wear  ;  one  and  one-fourth 
yard  of  drilling  makes  one  of  ordinary  size,  A  measure  is  taken  around 
the  body  just  above  the  pubes,  and  at  the  waist.  A  seam  is  cut  on  the 
hips  and  in  the  middle  of  the  back  to  make  it  fit  the  form,  and  the  band- 
age is  lapped  in  front,  over  a  cushion  made  of  hair,  which  is  placed  just 
above  the  pubes  to  make  the  necessary  pressure.  To  prevent  its  slipping 
out  of  place  elastic  tapes  are  fastened  on  the  bandage,  and  the  end  pinned 
to  the  stocking,  thus  serving  a  double  purpose." 

When  it  is  desired  to  exert  special  pressure  over  the  symphysis  pubis 
in  order  to  support  or  press  back  the  fundus  of  an  anteverted  or  ante- 
flexed  uterus,  these  uniformly  compressing  supporters  are  insufficient.  An 
oval  convex  pad  of  cotton  covered  with  cloth  or  kid  leather  may  be  at- 
tached to  the  inside  of  the  bandage  so  as  to  fit  immediately  above  the 


Fig.  178. — Home-made  Abdominal 
Supporter, 


ABDOMINAL    SUPPOETERS. 


349 


pubis  ;  or  a,  s]Decial  pad  attached  to  an  abdominal  band,  or  a  broad  steel 
spring  may  be  employed,  the  jDressure  being  directed  only  on  two  sjoots, 
over  the  pubis  and  the  lumbar  vertebrae.  This  spring  pad  is  constructed 
on  the  truss  principle,  and  is  illustrated  by  the  bandage  known  as  the 
ceinl lire  h  ijpogastriq  ue. 

A  very  good  supporter  for  this  jDurpose  is  the  cedarwood  pad  of  Thomas, 
which  consists  of  an  oblong  piece  of  smooth  cedarwood  about  six  inches 


Fig.  179. — Thomas'  Wooden  Pad  Supporter  for  Anteversion. 

long,  by  three  inches  wide,  by  two  inches  thick,  the  abdominal  surface  of 
which  is  convex,  so  as  to  press  deeply  into  the  abdominal  wall  above  the 
pubis.  I  generally  employ  the  shghtly  concave  hard-rubber  plate  of  an 
abdomino-vaginal  supporter  as  a  supra-pubic  pad,  having  the  concavity 
filled  out  by  leather  padding,  if  necessary.  I  have  found  great  benefit 
from  these  supra-pubic  pads  in  aggravated  anteversion,  being  even  able  to 
dispense  with  an  intra-vaginal  pessary  while  they  were  worn.  Thus  a  few 
years  ago,  while  on  my  vacation  in  the  country,  I  was  asked  to  see  a  city 
lady  who  was  confined  to  her  bed  by  an  inability  to  retain  her  uiine  when 
up.  I  found  an  anteverted,  hyperplastic  uterus,  which  no  doubt  rested 
on  the  bladder  when  the  patient  w^as  u]d.  I  sent  her  a  cedarwood  pad 
supporter  as  soon  as  I  returned  to  the  city,  and  with  it  she  was  at  once 
able  to  leave  her  bed  and  walk  about  with  almost  entire  comfort.  On  my 
return  to  the  country  two  weeks  later  I  added  a  Thomas  cup-pessary  (see 
Fig.  189),  and  thus  gave  her  uterus  all  the  necessary  sujoport.  In  another 
instance  a  young  lady  with  sharp  anteflexion  was  entirely  relieved  of  her 
supra-pubic  pain  and  bearing  down 
feeling,  and  enabled  to  walk  as  Avell 
as  in  health,  by  means  of  the  hard- 
rubber  plate  shown  in  Fig.  212.  Of 
course  this  supra-pubic  pressure  did 
not  remedy  the  version,  which  re- 
quired a  vaginal  instrument.  The 
abdominal  pad  merely  supported  the 
abdominal  viscera,  rendered  the  uterus  less  movable,  and  prevented  its 
pressing  on  the  bladder.  Thigh-straps  are  always  required  to  keep  these 
pads  in  place.  All  the  supporters  and  corsets  which  are  designed  to  lift 
up  and  compress  the  whole  abdominal  wall  should  be  sustained  by  broad 
bands  passing  over  the  shoulders  and  crossed  in  front  and  behind.  Or- 
dinary suspenders  will  answer  for  this  purpose,  or  the  abdominal  sup- 
porter may  be  buttoned,  hooked,  or  strapped  to  the  thoracic  corset,  which 
it  is  fair  to  assume  ninety-nine  out  of  one  hundred  of  all  women  still  wear, 


Fig.  ISO. — Ceinture  Hypogastrique. 


350  MINOR    GYNECOLOGICAL    MANIPULATIONS. 

in  spite  of  medical  protest.  If  the  corset  is  provided  with  a  cu-cular 
metal  border  resting  on  the  hips,  so  that  downward  pressure  on  the  yield- 
ing abdominal  wall  is  avoided,  it  can  do  no  harm,  and  any  weight  attached 
to  it  (such  as  an  abdominal  supporter,  and  chiefly  the  skirts)  wiU  hang 
from  the  shoulders. 

The  ordinary  T-bandage  is  useful  in  the  same  cases  as  Noeggerath's 
apparatus,  above  described,  and  is  chiefly  employed  to  apply  a  napkin  to 
the  vulva  during  menstruation  or  a  vaginal  leucorrhea,  or  to  prevent 
medicinal  agents  from  soiling  the  clothes,  or  tampons  or  pessaries  from 
escaping.  Every  woman  can  make  one  for  herself  of  cotton  or  linen  cov- 
ered with  oiled  silk.  The  genital  piece  is  attached  to  the  waistband  in 
front  and  behind,  or  the  bandage  may  be  in  one  piece. 

The  manner  of  enveloping  the  abdomen  with  broad  binders,  as  after 
labor  and  laparotomy,  does  not  properly  belong  to  this  woi'k. 

2.  Vaginai,  Supportees. 

Pessaries  which  are  contained  entirely  within  the  vagina  are  so  vari- 
able in  construction,  in  accordance  with  the  peculiar  features  and  neces- 
sities of  each  case  and  the  practice,  ideas,  and  hobbies  of  the  physician, 
that  their  number  is  legion,  and  it  wiU  be  absolutely  impossible  for  me  to 
enumerate  and  describe  them  all.  Besides,  it  would  be  entirely  unneces- 
sary to  do  so,  since  the  vast  majority  are  either  mere  trifling  modifications 
of  some  main  type,  to  each  of  which  the  ambitious  inventor  or  the  oblig- 
ino-  instrument  maker  has  given  the  former's  name,  or  they  are  mere  freaks 
of  fancy — theoretical  experiments — which  have  never  extended  beyond 
the  inventor's  practice  or  the  instrument  maker's  shop.  I  shall  endeavor 
to  describe  all  the  varieties  of  pessaries  for  each  displacement  of  the  uterus 
which  have  become  deservedly  or  undeservedly  popular,  explain  their 
advantages  and  disadvantages,  their  uses  and  abuses,  so  far  as  my  expe- 
rience has  enabled  me  to  judge ;  and  shall  refer  the  reader  for  the  study 
of  the  obsolete  and  useless  instruments  of  this  class  to  the  instrument 
makers'  catalogues  and  the  museums  of  our  medical  colleges.  In  no 
branch  of  mechanical  art  does  the  inventive  spirit  of  mankind  seem  to 
have  run  more  riot  than  in  the  production  of  pessaries,  with  the  only  ex- 
ception, perhaps,  of  the  obstetric  forceps. 

Pessaries  are  most  frequently  made  of  hard  rubber,  poHshed  to  such  a 
degree  of  smoothness  as  not  to  irritate  the  vaginal  walls  ;  but  they  may 
be  made  of  silver  or  aluminium  (the  lightness  of  the  latter  being  an  advan- 
tage), or  of  celluloid  ;  or,  if  a  flexible  instrument  is  desired,  we  have  them 
of  flexible  tin,  of  thick  copper  wire  covered  with  soft  rubber,  of  a  large 
watch-spring  also  covered  with  soft  rubber  ;  or  of  fine  strands  of  wire  laid 
together  so  as  to  put  the  end  of  each  strand  in  a  different  place,  also  ^vith 
soft  rubber  covering.  Finally,  for  large  flabby  vaginae  in  prolapsus  we 
have  inflatable  bags  of  soft  rubber,  glass  balls  and  rings,  canvas  rings  cov- 
ered with  japan,  wooden  rings,  etc. 

The  great  objection  to  all  pessaries  made  of  inflexible  material  is  that 


VAGINAL    SUPPORTERS.  851 

the  slmpe  of  the  instrument  cannot  be  changed  to  suit  the  peculiarities  of 
each  case,  and  that,  therefore,  a  large  assortment  of  different  sizes  and 
shapes  must  be  kept  on  hand  to  choose  fx'om.  In  a  city  with  instrument 
makers  at  hand  this  is  a  matter  of  little  consequence,  but  in  the  country' 
it  is  a  serious  evil  which  may  entirely  prevent  the  physician  from  rehev- 
ing  the  class  of  patients  for  whom  pessaries  are  needed.  And  even  in 
cities,,,the  inconvenience  of  having  to  make  a  new  appointment  with  your 
patient  until  you  are  able  to  procure  a  better  fitting  pessary  for  her,  in- 
stead of  being  able  to  shape  the  instrument  at  once  to  fit  her  case,  is  a 
matter  of  annoyance  to  both  parties.  The  hard-nibber  joessary,  to  be 
sure,  that  is  to  say,  the  variety  made  of  a  slender  ring,  can  be  bent  and 
moulded  by  being  covered  with  sweet  oil  and  carefully  heated  over  a  spmt- 
lamp,  or  in  boiling  water.  But,  over  the  lamp  the  inexperienced  ojDerator 
will  probably  blister  the  pessary  and  spoil  it  (for  a  pessary  with  a  rough 
surface  is  absolutely  useless  and  injurious) ;  and  in  hot  water  the  pessary 
is  seldom  sufficiently  heated  to  retain  its  flexibility  until  removed  and  bent 
to  the  desired  shape.  It  certainly  requires  a  greater  amount  of  practice 
and  dexterity  to  mould  these  hard-rabber  pessaries  than  the  majority  of 
practitioners  possess.  I  have  found  that  by  keeping  the  pessary  at  the 
spot  where  it  is  being  heated  constantly  covered  with  sweet-oil,  which  can 
be  contained  in  the  palm  of  the  other  hand,  or  in  a  vessel  close  by,  and  by 
moving  the  pessary  continually  over  the  flame,  as  a  rule,  blistering  can  be 
avoided.  A  good  plan  is  to  wait  until  the  pessary  is  so  soft  as  to  bend  or 
straighten  by  its  own  weight,  and  then  press  it  on  a  marble  slab  to  the  de- 
sired curve  and  pour  cold  water  over  it  or  hold  it  a  few  minutes  until  it 
is  set. 

To  furnish  us  with  a  pessary  flexible  at  will,  copper  wire  covered  with 
soft  rubber  was  introduced,  but  all  soft-rubber  pessaries  possess  the  great, 
irremediable  objection  of  absorbing  the  vaginal  secretions,  soon  becoming 
offensive,  and  of  irritating  the  tissues  by  a  gradually  increasing  roughness 
of  surface.  Soft  i-ubber  cannot,  it  seems,  be  so  treated  by  chemicals  as  to 
be  flexible,  and  at  the  same  time  remain  unaffected  by  the  acid  vaginal 
secretions.  So  far,  therefore,  we  must  of  necessity  rest  satisfied  with  in- 
flexible, if  indestructible,  hard-rubber,  and  flexible,  but  destructible,  soft- 
rubber  coated  wire  pessaries,  since  all  experiments  to  furnish  reliable  and 
durable  malleable  substitutes  have  failed.  Copper  wire  has  been  covered 
with  rubber  prepared  in  a  peculiar  manner,  so  as  to  preserve  a  smooth 
and  incorrodable  surface,  but  it  was  soon  found  to  crack  and  chip  ;  and 
the  celluloid  covering,  which  a  few  years  ago  was  thought  to  have  solved 
the  problem,  soon  proved  open  to  the  same  objection. 

The  flexible  rings  of  block  tin  and  copper,  uncovered  by  rubber,  are 
too  easily  roughened  by  deposits  of  vaginal  salts  on  them  to  be  of  more 
than  temporary  utility  as  models  after  which  hard  instruments  are  to  be 
constructed.  Not  onl}'  those  pessaries  which  require  to  be  modelled  to 
suit  each  case,  but  also  those  which  act  chiefly  by  their  bulk,  should  be  of 
unchangeable  material.  The  large  rings  for  prolapsus  uteri  should,  there- 
fore, be  of  glass  or  hard  rubber,  in  preference  to  canvas  and  soft  rubber. 


352  MliSrOR    GYNAECOLOGICAL    MANIPULATIOi^S. 

The  general  indications  for  vaginal  pessaries  are  of  course  some  form  of 
uterine  disj^lacement  or  distortion  (anteversion  or  anteflexion,  retroversion 
or  retroflexion,  latero-flexion,  prolapsus)  or  a  jjrolapsus  of  the  anterior  wall 
of  the  vagina  together  with  the  posterior  wall  of  the  bladder  (c3'stocele),  or 
of  the  posterior  wall  of  the  vagina  with  the  anterior  wall  of  the  rectum 
(rectocele).  Finally,  excessive  mobility  of  the  uterus,  resulting  in  alter- 
nating painful  pressure  by  the  fundus  on  the  bladder  or  rectum,  may 
require  a  pessary  merely  as  a  means  of  maintaining  the  uterus  in  one 
position. 

It  is  not  to  be  understood,  however,  that  every  displacement  or  distor- 
tion requires  a  vaginal  supporter ;  it  may  be  so  slight  as  to  produce  no 
symptoms  whatever,  or  it  may  not  distress  the  patient  even  though  severe. 
Thus  the  uterus  may  be  moderately  anteverted  or  anteflexed,  but  the  pa- 
tient suffer  neither  from  j)ressui'e  on  the  bladder,  nor  dysmenorrhea,  nor 
be  sterile  (the  usual  results  of  the  higher  degrees  of  these  displacements). 
Or  the  uterus  may  be  retroverted  only  in  the  first  degTee,  and  the  patient 
experience  no  annoyance  from  it,  or  there  may  be  a  more  severe  backward 
displacement  and  still  no  symptoms.  In  these  cases  it  may  not  be  neces- 
sary to  introduce  a  pessary,  especially  if  the  patient  is  advanced  in  years, 
unmarried,  or  beyond  the  child-bearing  period  ;  and  the  probabilities  are 
that  the  usual  atrophy  of  the  utenas  after  the  menopause  will  render  fut- 
ure annoyance  from  the  disjDlacement  still  less  likely.  Again,  the  replace- 
ment of  a  retroverted  uterus  and  its  supj)ort  by  a  pessary  may  give  the  pa- 
tient more  pain  than  if  the  case  is  let  alone  ;  or  repeated  attempts  show 
that  the  uterus  is  too  flabby  to  admit  the  pressure  of  a  pessar}',  or  the  va- 
gina is  too  short,  or  the  j)osterior  cul-de-sac  too  tender  to  bear  the  j^ressure 
always  exerted  by  a  jDessary. 

In  young  giris,  for  instance,  a  moderate  anteflexion  or  retroversion 
does  not  necessarily  call  for  a  vaginal  supporter  unless  the  symptoms  actu- 
ally require  local  interference.  In  ante-displacements  an  abdominal  pad 
will  often  suffice.  It  does  not  follow  that,  because  a  yoiuig  girl  has  a  dis- 
placement of  moderate  degree  she  will  thereby  necessarily  be  unfitted  for 
marriage  and  maternity.  Still,  I  have  generally  followed  the  rule,  that  if  a 
displacement  of  anything  more  than  the  first  degree  is  discovered  in  a 
young  woman  who  exjDects  to  be  married  soon,  and  who  consults  a  physi- 
cian for  one  of  the  local  signs  of  uterine  disease  (backache,  bearing  down, 
dysmenorrhea),  that  displacement  should  be  rectified  as  much  as  possible 
before  she  should  be  allowed  to  many.  Treatment  is  much  easier  and 
more  effectual  then  than  later,  when  the  excitements  and  requirements  of 
married  life  fully  occupy  the  sexual  organs.  No  man  hkes  to  have  his  wife 
suffer  from  uterine  disease  and  be  subjected  to  local  treatment,  by  pes- 
saries or  otherwise,  almost  before  the  houej'moon  is  over.  And  his  feelings 
are  not  always  free  from  selfishness,  for  his  own  comfort  is  disturbed 
thereby.  Besides,  a  displacement  is  always  moi-e  or  less  aggravated  by 
the  mechanical  and  vascular  initation  of  the  sexual  organs.  Therefore  it  is 
always  best  to  endeavor  to  cure  uterine  disease,  rectify  a  displacement,  be- 
fore marriage,  even  though  the  discomfort  therefrom  be  but  shght  at  the 


VAGINAL    SUPPORTERS.  353 

time.  The  chances  are  that  marriage  will  arouse  symptoms  which  have 
not  yet  aj^pearecl. 

Further,  many  patients  present  themselves  with  displacements,  chiefly 
backward,  in  whom  a  pessary  is  inadmissible, because  the  displacement  can- 
not be  rectified  ;  the  uterus  being  held  down  by  adhesions  remaining  from 
an  attack  of  peritonitis  or  cellulitis.  Before  a  pessary  can  be  worn  with 
benefit  and  comfort,  these  adhesions  must  be  dispersed  or  stretched,  and 
months  are  usually  required  to  do  this,  if  indeed  it  be  possible  at  all.  In 
some  cases,  however,  this  very  stretching  may  be  accomphshed  by  the  pes- 
sary itself  ;  but  such  cases  are  the  exception,  and  must  be  cai-efully  watched 
lest  the  pressure  rekindle  the  inflammation  or  j^roduce  ulceration. 

In  displacement  of  the  vaginal  walls — cystocele  and  rectocele — the 
amount  of  displacement  and  the  discomfort  experienced  therefrom,  will 
influence  the  necessity  and  choice  of  a  pessary.  If  there  be  a  loss  of 
support  for  the  posterior  wall  (whereby  the  anterior  wall  may  also  become 
displaced)  through  destruction  of  the  perineum,  the  restoration  of  that 
part  by  a  plastic  operation  is  called  for  before  a  proj)erly  fitting  su2:)porter 
can  be  used  with  benefit.  To  follow  the  old  time-  (biat  not  otherwise) 
honored  practice  of  holding  up  the  prolapsed  parts  by  crowding  a  large 
globular  or  annular  suj)porter  into  the  vagina,  which  acts  only  by  its  size, 
is  not  treating  the  case  scientifically. 

In  prolapsus  uteri  et  vaginae,  when  the  whole  mass  protrudes  from  the 
vulva,  a  supporter  is  called  for  in  the  highest  degree.  But  the  difficulty 
is  not  to  form  an  indication  for  a  supporter  in  these  cases,  but  to  find  the 
instniment  which  will  keep  up  the  uterus  and  produce  neither  pain  nor 
ulceration  by  pressure. 

Sterility  due  to  a  displacement  (ante-  or  retro-)  calls  for  a  reposition  of 
the  organ  and  its  retention  by  a  pessary.  When  conception  has  taken 
place,  the  retention  of  the  pessary  is  still  imj^ortant,  because  if  it  were 
removed,  the  uterus  might,  and  in  consequence  of  its  increased  weight 
probably  would,  again  become  displaced,  and  the  thereby  induced  conges- 
tion might  readily  bring  on  a  miscarriage.  For  the  same  reason,  if  a 
uterus  enlarged  by  early  pregnancy  is  found  displaced  it  should  be  re- 
stored to  its  normal  position  and  retained  by  a  pessary.  This  inile  applies 
chiefly  to  retro-displacement.  In  ante-displacement  the  growth  of  the 
organ  during  pregnancy  usually  accomplishes  the  rectification  by  itself. 
Impregnation  of  a  retro-displaced  uterus  is  therefore  a  direct  indication 
for  a  pessar}',  which  should  be  worn  until  the  growth  of  the  organ  has 
brought  the  fundus  above  the  promontory  of  the  sacrum,  that  is,  till  about 
the  beginning  of  the  fourth  month. 

Occasionally  the  vomiting  of  pregnancy  is  arrested  by  the  replacement 
of  a  dislocated  uterus,  and  its  retention  by  a  pessary.  A  vaginal  examina- 
tion is  therefore  always  advisable  when  the  vomiting  is  more  than  usually 
severe  or  intractable. 

Counter-indications  to  the  use  of  pessaries  are  of  course  the  absence  of 
a  properly  formulated  indication,  such  as  already  described  ;  further  acute 
inflammation  of  the  uterus  and  adnexa,  and  of  the  vagina,  and  chi-ouic  in- 
23 


354  MIlSrOK    GYNECOLOGICAL    MANIPULAnOlSrS. 

flammation  of  these  parts  when  the  pressure  of  the  finger  gives  pain  or  the 
displacement  is  due  to  adhesions  which  prevent  the  reposition  of  the 
uterus.  A  profuse  leucorrheal  discharge  may  also  counter-indicate  a 
pessary  for  the  time  being,  because  the  unavoidable  irritation  of  every 
pessary  produces  a  vaginal  discharge  and  of  course  will  aggravate  one 
ah-eady  existing.  A  cervical  or  intra-uterine  discharge  does  not  do  so,  be- 
cause the  chronic  congestion  upon  which  the  discharge  depends  may  be 
due  to  the  displacement  and  will  be  relieved  by  the  reposition  and  reten- 
tion of  the  uterus  in  its  normal  position. 

A  laceration  of  the  cervix  may  counter-indicate  a  pessary,  because  the 
fixation  of  the  vaginal  walls  by  the  pessary  tends  to  separate  the  everted 
lips.  The  question  which  of  the  two  affections,  the  displacement  or  the 
laceration,  gives  the  most  trouble  will  then  have  to  be  decided  ;  generally 
the  displacement  will  carry  the  day. 

Married  life  does  not  counter-indicate  the  wearing  of  a  pessary,  unless 
the  husband  absolutely  objects  to  any  foreign  body  in  the  vagina  of  his 
wife.  The  slender,  smooth,  and  accurately  fitted  pessaries  now  generally 
used  do  not,  as  a  rule,  interfere  with  coition,  if  the  wife  be  informed  by 
her  physician  how  to  adjust  the  pessary  for  the  moment  in  case  it  should 
chance  to  be  in  the  way.  This  advice  will  consist  chiefly  in  showing  the 
wife  how  to  keep  the  anterior  curve  of  a  lever  pessary  pressed  against  the 
symphysis  pubis  with  the  finger  at  the  moment  of  intromission,  and  in 
directing  the  husband  to  be  particularly  gentle  and  avoid  deep  insertion. 
Frequently  it  is  advisable  not  to  inform  the  husband  of  the  presence  of  a 
pessary,  to  which  he  might  object  and  which  he  does  not  discover.  But 
recently  a  patient  wearing  a  Gehrung  j^essary  for  cystocele  told  me  that 
her  husband  had  not  yet  become  aware  of  the  fact  that  she  was  wearing 
such  an  instrument,  although  coition  had  been  performed  many  times 
since  its  introduction.  Violent  coition  may  naturally  give  pain  under 
such  circumstances  or  displace  the  pessary. 

The  rule  is  to  remove,  as  far  as  possible,  all  counter-indications  before 
applying  a  pessary,  and  this  preparatory  treatment  may  occupy  months. 

General  Considerations  influencing  the  Selection,  Application,  and  Manage- 
ment of  Pessaries. 

There  is  probably  no  therapeutic  measure  in  gynecological  practice 
which  is  so  little  understood  and  so  thoroughly  mismanaged  as  the  use  of 
pessaries.  On  the  ignorance  of  the  practitioner  will,  in  the  large  majority 
of  cases,  depend  his  want  of  success  in  fitting  a  pessary  so  that  it  will  re- 
tain the  uterus  in  its  proper  position  ;  and  of  course  the  fault  is  never 
sought  in  himself,  but  is  always  attributed  to  the  pessary.  A  very  com- 
mon error  is  to  choose  too  large,  too  sharply  bent  instruments,  which  do  ■ 
too  much  and  crowd  the  uterus  into  another  position  quite  as  distressing 
as  the  original  displacement.  Next  to  the  proper  selection  and  fitting  of 
an  instrument  to  each  particular  case,  the  omission  to  watch  it  and  pre- 
vent its  doing  injury  by  pressure  or  becoming  displaced,  and  the  too  long 


MANAGEMENT    OF    PESSARIES.  355 

retention  of  the  same  instrument  without  a  change  or  occasional  removal, 
are  the  causes  of  the  disaj)pointment  and  unpleasant  effects  experienced 
by  many  practitioners. 

Properly  selected,  adjusted,  and  watched,  vaginal  j)essaries  are  not 
only  most  useful,  but  actually  indispensable  instruments  in  the  treatment 
of  uterine  displacements.  It  is  their  abuse,  not  their  use  which  has 
brought  them  into  discredit  with  some  physicians. 

Mode  of  action. — Vaginal  pessaries  act  in  three  ways  :  1,  by  their  size 
(balls  and  thick  rings  of  firm  material  in  prolaj)sus)  ;  2,  by  the  direct 
support  which  they  give  to  the  uterus  or  vagina  (whether  replaced  or  not), 
without  themselves  attempting  to  restore  the  normal  condition  (in  ante- 
version  and  anteflexion,  cystocele,  rectocele)  ;  and  3,  by  a  peculiar  lever 
action  which  tends  to  replace  the  displaced,  then  always  retroverted  fundus 
uteri  (all  the  ring  pessaries  constructed  after  the  principle  of  Hodge's 
closed  lever  pessary). 

1.  Pessaries  ivhich  act  hy  their  size  cannot  be  considered  ciu-ative,  since 
they  necessarily  distend  the  vaginal  walls  to  their  utmost  limit  in  order  to 
insui-e  their  retention,  and  therefore  weaken  and  prevent  them  from  con- 
tracting and  regaining  their  tone.  These  pessaries  are  but  makeshifts, 
and  are  allowable  only  where  no  other  curative  mechanical  appliance  or  an 
operation  is  practicable.  In  women  long  past  the  menopause,  with  flabby 
vaginae,  small  uteri,  relaxed  and  atrophic  ligaments  and  tissues,  whose 
sexual  organs  have  passed  the  period  of  functional  activity  and  usefulness, 
it  is  permissible  to  lessen  the  chances  of  a  permanent  cure  by  increasing 
the  very  condition  which  produced  the  displacement,  viz.,  the  relaxation 
of  that  great  uterine  support,  the  vagina.  In  these  cases,  and  they  are  all 
instances  of  more  or  less  complete  j)rolapse  of  uterus  and  vagina,  we  ex- 
pect no  cure,  we  know  none  is  possible  with  or  without  operation,  and  we 
merely  wish  to  make  the  patient  as  comfortable  as  possible  for  the  re- 
maining minority  of  her  life,  by  keeping  the  prolapsed  organ  within  the 
body. 

In  young,  sexually  still  vigorous  women,  with  tissues  which  yet  admit 
of  restoration  to  tone  and  health,  it  seems  to  me  unjustifiable  to  injure 
them  permanently  and  destroy  their  hopes  of  permanent  cure,  by  stretch- 
ing their  vaginae  to  the  utmost  with  large  disks  or  globes,  or  by  elastic 
flexible  rings  which  are  retained  only  through  their  constant  centrifugal 
expansion.  We  should  restore  the  parts  to  their  normal  condition  as 
nearly  as  possible  by  astringents,  by  supports  which  contract  while  they 
support,  and  if  need  be  by  operation,  and  then,  if  still  necessary,  intro- 
duce a  properly  fitting  pessary,  which,  if  it  does  not  cure,  does  not  at  all 
events  preclude  the  hope  of  improvement. 

The  cases  to  which  these  remarks  apply  are  solely  cases  of  prolapsus 
of  the  uterus  and  vagina,  and  of  rectocele  and  cystocele. 

2.  Pessaries  which  act  only  hy  the  direct  support  they  give  to  the  dis- 
placed part  will  be  described  in  the  sections  on  Anterior  and  Lateral  Dis- 
placements, and  Displacements  of  the  Vaginal  AVall.  These  pessaries,  in 
order  to  afford  this  support,  must  of  course  have  a  base  upon  which  to 


356  MINOR    GYNECOLOGICAL    MANIPULATIONS. 

rest.  This  base  is  generally  offered  by  the  contractile  walls  of  the  vagina, 
or  by  the  perineum  or  floor  of  the  pelvis,  or  the  symphysis  jDubis.  They 
act  merely  as  spUnts  to  the  displaced  part,  preventing  it  from  becoming 
still  more  disj^laced,  and  thus,  it  is  true,  in  an  indirect  mannei',  give  the 
attachments  of  the  dislocated  organ  an  opportunity  to  recover  their  tone 
and  vigor.  It  .is  in  this  manner  that  all  anteversion  and  anteflexion  pes- 
saries prove  beneficial  and  (perhaps)  ultimately  curative.  As  compared 
with  the  pessaries  next  to  be  described,  the  pessaries  for  ante-displace- 
ments occupy  a  somewhat  insignificant  position,  and  could  be  more  easily 
disj)ensed  with  than  even  those  which  act  merely  by  their  size.  Ante- 
version  of  the  uterus  is  only  occasionally  of  sufficient  severity  to  give  rise 
to  serious  inconvenience.  Emmet  even  asserts  that  it  is  not  the  anteversion 
which  causes  the  distressing  supi-a -pubic  weight  and  dragging,  but  the 
simultaneous  downward  displacement  of  the  uterus,  and  that  all  antever- 
sion pessaries  act  by  hf  ting  the  whole  uterus  up,  not  merely  by  supporting 
the  fundus.  To  a  certain  extent  I  believe  he  is  right,  but  I  certainly  have 
seen  pessaries  which  merely  kej)t  the  fundus  away  from  the  bladder,  with- 
out materially  lifting  up  the  whole  uterus  (such  as  Gehrung's,  Fig.  182,  and 
Thomas'  open  cup  pessary,  Fig.  189),  give  great  relief.  In  anteflexion  the 
same  may  be  asserted,  since  no  severe  anteflexion  was  probably  ever  cured, 
no  uterus  entirely  straightened,  by  an  anteflexion  pessary.  The  flexion 
may  be  slightly  diminished  by  the  support  which  the  fundus  gets  from  the 
upper  rim  of  the  pessary,  and  j^erhaps  by  the  slight  backward  extension  of 
the  cervix,  but  on  removal  of  the  instrument  the  angle  at  once  returns. 
Dysmenorrhea  will,  however,  be  reheved,  and  sterility  may  be  cured  by 
this  slight  diminution  of  the  angle  of  flexion. 

Vaginal  prolapse  can  be  cured  in  time  by  these  pessaries,  provided  the 
necessary  supj)ort  of  the  perineum  is  not  entirely  lost  or  is  restored  by 
operation.  Recently  a  most  excellent  instrument  has  been  devised  by 
Gehrung,  the  largest  size  of  which  accomiDlishes,  in  many  cases,  what  no 
other  intra-vaginal  j)essaiy  has  done  before,  excej^t  through  its  size,  viz.,  to 
retain  a  prolapsed  uterus  simply  by  supporting  the  also  prolapsed  anterior 
wall  of  the  vagina. 

3.  The  jiessai^ies  which  act  by  a  peculiar  lever  action,  and  by  that  action 
strive  to  restore  the  disj^laced  uterus  to  its  normal  position,  are  by  far  the 
most  numerous,  the  most  frequently  needed,  the  most  beneficial,  and  the 
most  indispensable.  They  are  used  exclusively  for  retro-displacements, 
either  version  or  flexion.  They  are  all  oblong  rings  constructed  on  the 
single  or  double  lever  princii)le  first  introduced  into  the  doctrine  of  pes- 
saries by  the  late  Dr.  Hugh  L.  Hodge,  of  Philadelphia,  some  twenty-five 
years  ago.  Since  then  numerous  modifications  of  his  original  instrument 
have  been  made,  but  the  lever  princij)le  has  been  preserved  in  all  of  them. 
The  shape  of  the  Hodge  pessary  is  shown  in  Fig,  192.  One  curved  end  (the 
shorter)  goes  behind  the  cervix,  the  other  (longer)  in  front  against  the  an- 
terior vaginal  wall.  The  patient  now  being  erect,  the  weight  of  the  bladder 
and  intestines,  aided  by  the  increased  normal  intra-abdominal  jDressure 
dui-mg  inspu-ation  and  walking,  presses  the  anterior  bow  of  the  pessary 


MANAGEMENT    OF    PESSAEIES. 


357 


downward,  and  naturally  tilts  tlie  posterior  end  up,  and  with  it  the  retro- 
displaced  fundus  uteri.  Therefore,  in  the  very  position  in  which  the 
patient  needs  the  replacement  and  support  most,  in  the  erect,  the  force 
necessary  to  produce  this  admirable  lever  action  is  supplied  by  natural 
means. 

If  the  uterus  is  not  entirely  replaced  before  applying  the  pessary  when 
the  patient  stands,  the  backward  and  downward  joressure  of  the  still  some- 
what retro-displaced  fundus,  with  the  weight  of  the  superincumbent  mas- 
cara, wiU  rest  on  the  posterior  arm  of  the  lever  and  thus  tilt  up  the  longer 
anterior  arm  against  the  neck  of  the  bladder.  The  pressiu-e  there  may  be 
so  severe  as  to  be  unbearable.  The  importance  of  entirely  replacing  the 
uterus  before  applying  a  pessary  is  therefore  apparent.  \Vhen  the  woman 
lies  down  the  weight  of  the  viscera  relieves  the  fundus  and  the  posterior 


Pig.  181. — Emmet's  Retroversion  Lever  Pessary  Supporting  Uterus  (Emmet). 


arm  of  the  pessary,  and  the  anterior  arm  becomes  loose.  This  constant 
rocking  motion,  which  is  exerted  by  every  well-fitting  lever  pessary, 
whether  the  uterus  is  entirely  replaced  or  not,  slightly  changes  the  jDosi- 
tion  of  the  instrument  each  time,  and  thus  avoids  too  steady  jDressure  on 
one  spot.  But  the  position  of  the  uterus  is  not  materially  changed  diu'ing 
the  rocking  of  the  pessary,  for  the  latter  will  always  regain  its  position 
behind  the  cervix  as  soon  as  the  backward  pressure  by  the  uterus  is  re- 
lieved in  the  horizontal  position. 

When  the  uterus  has  been  entirely  replaced,  as  it  should  be  before  the 
pessary  is  fitted,  this  action,  in  my  opinion,  is  reversed,  and  the  pressure 
in  standing  is  exerted  on  the  anterior  arm,  and  in  lying  down  on  the  pos- 
terior. The  latter,  however,  will  be  minimal  if  the  uterus  remains  re- 
placed ;  only  the  slight  backward  tendency  of  the  fundus  produced  by  the 
dorsal  position  will  be  observed. 

In  accordance  with  this  difference  of  leverage,  as  the  fundus  is  replaced 


358  MrsroR  gyjstecological  ma]S"ipulatiox3. 

anteriorly  or  not,  a  lever  pessary  will  but  very  rarely  succeed  in  replacing 
a  retro-dislocated  uterus.  Its  constant  pressure  may  elongate  the  j)oste- 
rior  vaginal  wall,  but  only  by  accidental  changes  of  position  "will  the  uterus 
be  anteverted  while  the  pessary  is  worn.  If,  however,  the  anterior  bar  of 
the  pessaiy  derives  its  support  from  the  immovable  pubic  bones,  then  its 
steady  pressure  may  finally  lift  up  the  fundus.  Such  pessaries  wiU  be  de- 
scribed further  on,  and  are  often  very  useful. 

In  many  pessaries  the  anterior  arm  of  the  lever  is  elongated  in  order 
to  conform  more  to  the  shape  of  the  vagina  and  prevent  the  pessary  from 
tui-ning  in  the  vagina.  The  princijDle,  however,  always  remains  the  same  ; 
the  pressure  on  the  anterior  arm  is  merely  distril^uted  over  a  somewhat 
larger  area.  The  amount  of  leverage  depends  entirely  upon  the  curve  of 
the  pessary.  Pessarie  with  sharp  curve  of  the  posterior  bow  (that  which 
is  to  go  behind  the  cervix)  will  exert  a  more  powerful  lever  action  on  the 
retro-cer\dcal  tissue  than  those  with  but  a  moderate  curve. 

The  shai-per  the  curve  the  higher  will  the  uterus  be  lifted,  and  the 
more  will  its  hgaments  be  stretched  ;  this  hyper-tension  may  be  so  ex- 
treme as  to  give  rise  to  as  much  discomfort  as  the  original  disjDlacement. 
It  is  therefore  all-important  to  properly  estimate  the  amount  of  leverage 
required  and  permitted  by  the  degree  of  displacement,  the  depth  of  the 
posterior  vaginal  pouch,  and  the  weight  of  the  uterus,  in  choosing  a  pes- 
sary for  a  particular  case.  If  too  great  a  leverage  is  exerted,  the  uterus 
may  be  anteverted  ;  or  what  is  even  more  likely,  the  sharp  curv^e  of  the 
posteiior  bow  will  cause  the  pessary  to  press  so  firmly  into  the  posterior 
wall  of  the  uterus  at  the  vaginal  junction,  as  to  bend  the  organ  backward 
over  the  pessarj-,  and  thus  substitute  a  retroflexion  for  a  retroversion. 
The  curve  of  the  anterior,  or  pubic  extremity  shoiild  correspond  in  degree 
to  the  posterior  or  uterine  arm,  that  is,  the  greater  the  latter,  the  greater 
also  the  former. 

The  line  of  support  of  these  lever  pessaries  is  not  to  be  sought  at  any 
one  spot,  neither  at  the  symphysis  pubis,  nor  the  posterior  vaginal  wall, 
nor  the  retro-cervical  pouch  ;  but  wherever  the  pessary  touches  the  vaginal 
surface  it  has  a  certain  amount  of  cohesion,  and  if  properly  fitted,  and  the 
vaginal  walls  have  their  normal  contractility,  the  pessary  is  grasped  by 
them  and  securely  held.  It  moves  as  they  move,  and  needs  no  fixed 
fulcrum  upon  which  to  hinge.  Still,  in  order  to  have  a  lever  action,  it 
must  have  a  resting  point  somewhere,  and  this  point,  in  my  opinion,  is 
that  portion  of  the  vagina  extending  from  slightly  below  the  level  of  the 
cervix  to  the  apex  of  the  posterior  vaginal  pouch.  In  this  posterior  pouch 
the  posterior  curved  bow  of  the  pessary  rests,  and  if  the  uterus  is  properly 
replaced,  is  caught  there,  as  it  were,  by  suction.  Whatever  fulcrum  the 
pessary  has  is  at  about  the  level  of  the  external  os  on  the  posterior  vaginal 
wall.  If  this  posterior  wall  is  relaxed,  or  the  support  of  the  perineum 
lost,  the  ^^  hke  curve  of  the  wall  is  destroyed,  and  this  resting-place  for 
the  pessary  is  wanting  ;  the  instrument,  therefore,  is  not  retained,  glides 
down,  or  must  be  so  large  or  so  broad  in  front  as  to  act  by  its  size.  Its 
size  and  shape  then  retain  it,  and  the  pubic  bones  serve  as  a  fulcrum  for 


MAISTAGEMENT    OF    PESSAEIES.  359 

tlie  lever  action.  But  it  should  be  understood  that  in  a  normal  vagina, 
with  proper  posterior  wall,  the  pessary  has  no  fixed  point  as  a  fulcrum, 
least  of  all  the  symphysis  pubis.  This  is  precisely  the  advantage  of  the 
lever  pessary,  and  the  reason  why  it  is  more  easily  borne  than  any  other 
variety.  The  only  point  where  prolonged  pressure  of  even  a  small  retro- 
version pessary  occasionally  produces  excoriation  is  in  the  posterior  cul- 
de-sac,  on  the  posterior  aspect  of  the  cervix.  A  well-fitting  pessary  should 
never  reach  to,  and  certainly  not  below,  the  pubic  arch.  Those  pessaries 
which  fit  best  and  can  be  worn  the  longest  without  removal  or  injury,  are 
such  as  are  grasped  in  the  posterior  vaginal  pouch  by  the  suction  spoken 
of,  and  the  anterior  curve  of  which  hangs  almost  free  in  the  vagina, 
merely  touching  the  anterior  wall. 

In  some  cases  a  lever  action  is  not  desired,  and  still  a  lever  pessary  is 
used.  Such  are  cases  with  flabby  relaxed  vagina,  heavy,  deep-seated 
uterus,  gaping,  flabby  vaginal  orifice  ;  and  the  pessary  is  used  as  a  mere 
vsupport  by  its  size  and  shape.  A  broad,  but  slightly  curved  Hodge  is 
then  used,  which  is  retained  through  its  broad  anterior  bar  pressing 
against  the  pubic  bones.  An  indentation  in  the  transverse  anterior  bar, 
saves  the  sensitive  urethra  from  pressure.  This  form  of  pessary  is  also 
useful  in  excessively  movable  uterus. 

Certain  gynecologists  do  not  believe  in  this  "  lever-action  "  of  the  lever 
pessary  and  claim  that  it  elevates  the  retro-displaced  fundus  uteri  by  stretch- 
ing the  posterior  vaginal  pouch  backward,  thus  dragging  the  cervix  also 
backward  and  thereby  throwing  the  fundus  forward.  I  do  not  doubt 
that  this  traction  force  exerts  some  influence,  chiefly  in  dislodging  the 
fundus  from  the  sacral  excavation  (if  the  uterus  has  not  been  rej)laced)  or 
in  tilting  the  fundus  still  more  forward  (if  the  organ  has  been  anteverted). 
But  I  have  found  the  very  pessaries  which  held  up  the  uterus  best  and 
served  gradually  to  restore  the  organ  to  its  normal  position,  to  be  those 
which  did  not  stretch  the  posterior  vaginal  vault  backward,  and  in  which 
the  increase  of  curve  brought  the  lever  principle  fully  into  f)lay.  By  ex- 
amining a  patient  wearing  a  lever  pessary  first  lying  on  her  back  and  then 
standing,  the  difference  of  leverage  on  the  retro-cervical  tissues  can  be  at 
once  appreciated. 

Hoio  to  Adjust  Pessaries. — A  cardinal  rule  in  the  employment  of  pes- 
saries is,  to  fit  every  pessary  to  every  case.  There  are  as  many  different 
shapes  and  sizes  of  vagina  as  there  are  of  hands  and  feet,  and  every  woman 
has  her  own  peculiar  vagina  as  she  has  her  face.  While,  therefore,  many 
pessaries  may  fit  many  vaginae,  exactly  as  one  size  of  gloves  or  shoes  may 
fit  many  different  people,  this  is  only  because,  among  many  vaginse,  there 
may  possibly  be  a  certain  number  alike.  Only  by  careful  examination  and 
measurement  can  the  dimensions  of  the  vagina  be  ascertained,  and  in  ac- 
cordance with  the  result  obtained,  the  proper  variety,  shape,  and  size  is 
selected.  Emmet  relates  that  among  five  or  six  hundred  old  pessaries  in 
his  office,  which  had  been  in  as  many  vaginae,  there  were  not  to  be  found 
two  exactly  alike.  To  a  man  Avith  Emmet's  own  peculiar  mechanical  in- 
genuity and  dexterity,  and  holding  his  views  on  the  dependence  of  uterine 


360  MINOR    GYNECOLOGICAL    MANIPULATIOISTS. 

displacements  on  contractions  of  the  ligaments  and  para-uterine  cellular  tis- 
sue, this  enormous  variety  of  vaginal  pessaries  undoubtedly  appears  indis- 
pensable. Fortunately  for  the  general  practitioner  and  the  man  without 
special  mechanical  ingenuity,  it  is  not  always  necessary  to  have  the  pes- 
sary fit  every  fold  and  curve  of  the  vagina  with  absolute  accuracy.  Many 
patients  can  be  benefited  and  cured  by  using  the  pessaries  which  are  kept 
wholesale  in  the  shops,  and  which  are  made  in  certain  fixed  sizes  and 
shapes.  But  one  thing  is  certain,  and  that  is  that  no  man  without  at  least 
a  certain  amount  of  mechanical  knack,  can  hope  to  benefit  his  patients 
with  pessaries.  In  the  old  times  when  the  object  of  all  pessaries  was 
merely  to  lift  up  or  sustain  the  uterus  without  regard  to  the  variety  of  dis- 
placement, and  with  no  curative  object  in  view,  of  course  anybody  could 
adopt  one  of  the  crude  pessaries  then  in  use.  Bat  the  scientific  and 
rational  employment  of  our  present  vaginal  supporters  requires  not  only  a 
thorough  knowledge  of  the  normal  sexual  organs  and  their  surroundings, 
and  an  intimate  acquaintance  with  the  pathological  condition  in  each  par- 
ticular case,  but  also  a  certain  amount  of  mechanical  ingenuity  and  manual 
dexterity.  Without  these  requirements,  the  opei-ator  is  more  likely  to  do 
his  patients  harm  than  good,  and  will  probably  disappoint  them,  as  much 
as  he  will  himself  be  mortified  at  the  failure  of  his  efforts.  But,  probably 
he  will  console  himself  by  blaming  the  pessary! 

This  dexterity  in  modelling  and  shaping  pessaries  can  really  never  be 
thoroughly  acquired,  unless  an  inherent  mechanical  skill  is  present.  The 
practitioner  need  not  therefore  be  ashamed  of  his  want  of  success,  for  not 
every  one  of  us  can  be  an  Emmet  or  a  Thomas.  And  a  clear  understand- 
ing of  the  nature  of  the  case  and  of  the  treatment  required  will  enable  the 
majority  of  physicians  to  benefit  their  patients  with  displacements  very 
materially. 

To  secure  a  perfectly  fitting  pessar}',  Emmet  models  one  of  soft  block- 
tin  for  every  case,  lets  the  patient  wear  it  until  he  has  satisfied  himself 
that  it  suits  her,  and  then  has  it  reproduced  in  hard  rubber  or  aluminium. 
In  this  way  a  perfect  fit  must  be  obtained,  provided  the  original  model 
was  correct.  Many  phj'sicians,  who  find  none  of  their  supply  of  pessaries 
to  fit  a  certain  case,  use  the  pessaries  of  copx^er  wire  covered  with  soft 
rubber,  moulding  them  to  the  desired  shape  ;  and  I  confess  my  preference 
for  these  to  those  of  tin,  because  the  latter  ai'e  too  thin  and  liable  to  bend 
or  cut  into  the  tissues.  These  soft-rubber  pessaries  can  be  worn  for  sev- 
eral weeks  or  longer  with  proper  regard  to  cleanliness,  therefore  quite 
long  enough  to  judge  whether  the  shape  is  a  good  one  and  should  be  fixed 
in  hard  rubber. 

As  yet,  hard  rubber  is  universally  employed  for  vaginal  pessaries,  and 
certainly  is,  by  its  durability,  high  j)olish,  neatness  and  cheapness,  the 
best  material.  Only  when  it  becomes  necessary  to  change  the  shape  of 
the  pessar}^,  is  the  need  of  a  flexible  material  felt  which  shall  possess  the 
durability  and  the  other  good  qualities  of  the  hard  rubber.  As  already 
stated,  the  material  to  supply  that  M^ant  is  still  undiscovered. 

In  estimating  the  variety,  size,  and  shape  of  a  pessary,  the  physician 


MA2«"AGEMENT    OF    PESSAKIES.  361 

should  ascertain :  1,  tlie  nature  and  degree  of  tlie  displacement ;  2,  the 
mobility  of  the  uterus  ;  3,  the  length  and  width  of  the  vaginal  canal ;  4, 
the  dilatability  and  contractility  of  its  walls ;  5,  the  dejith  and  width  of 
the  posterior  vaginal  pouch  when  the  uterus  is  replaced  (this  applies  par- 
ticularly to  retro-displacements) ;  6,  the  weight,  size,  and  density  of  the 
uterus  ;  7,  the  dimensions  and  length  of  the  intra- vaginal  portion  of  the 
cervix  ;  8,  the  presence  or  absence,  and  the  seat  of  any  tenderness  in  the 
parametrium  or  uterus  ;  9,  the  degree  of  laceration  of  the  perineum,  or  of 
support  afforded  by  that  body  if  not  torn  ;  10,  the  amount  of  vaginal  se- 
cretion ;  11,  the  tension  of  the  anterior  vaginal  wall  with  the  bladder  ;  12, 
the  presence  of  a  prolapsed  ovary  at  the  bottom  of  Douglas'  pouch. 

The  nature  and  degree  of  the  displacement  is,  of  course,  the  first  thing 
to  be  ascertained.  That  unknown  or  uncertain,  the  selection  of  a  sup- 
porter is  impossible.  The  diagnosis  is  made  either  by  finger  and  bimanual 
method,  or  by  the  sound,  as  already  described.  The  degree  of  displace- 
ment is  marked  in  the  same  manner,  and  from  it  and  the  symptoms  the 
necessity  and  variety  of  the  pessary  determined.  This  is  usually  a  simple 
enough  matter.  But  the  particular  shape,  size,  and  curve  of  the  instru- 
ment is  by  no  means  so  easy,  and  to  decide  ujDon  these  j)oints  the  other 
factors  enumerated  should  be  inquired  into. 

The  mobility  of  the  uterus  is  certainly,  next  to  the  nature  of  the  dis- 
placement, the  most  important  point  in  this  whole  question,  especially  as 
regards  prognosis  ;  for  what  good  does  it  do  us  to  know  how  the  uterus  is 
displaced,  if  it  is  fixed  and  immovable  by  cellulitic  and  peritonitic  adhe- 
sions and  cannot  .be  replaced  ?  As  no  pessary  should  be  introduced  with- 
out the  uterus  having  previously  been  replaced,  the  effort  to  accomj)lish 
this  should  be  made  after  one  of  the  methods  described  in  the  respective 
chapter.  If  it  fails,  the  idea  of  placing  a  pessary  should  be  abandoned, 
unless  in  the  occasional  instances  where  the  adhesions  are  so  old  and  elas- 
tic that  an  effort  may  be  made  to  stretch  them  by  the  steady  upward  lever- 
age of  the  posterior  end  of  the  pessary  (this  also  applies  only  to  retro- 
displacements).  If  the  attempt  succeeds,  the  pessary  should  not  be  api^lied 
until  perfect  replacement  has  been  obtained.  The  depth  of  the  posterior 
vaginal  pouch  is  vastly  greater  when  the  uterus  is  antevei'ted  than  when 
the  retro-displaced  fundus  presses  it  down. 

The  length  and  width  of  the  vaginal  canal  will  determine  the  breadth 
and  length  of  the  pessary. 

The  vaginal  orifice  may  be  quite  large  and  still  the  vagina  narrow  with 
healthy,  contractile  walls  ;  or.  on  the  other  hand,  the  orifice  may  be  nar- 
row and  the  vaginal  pouch  roomy  and  spherical.  In  the  latter  case  a  larger 
pessary  may  be  needed  than  can  easily  be  passed  through  the  vaginal  ori- 
fice, and  strong  retraction  of  the  perineum  is  required  to  admit  it. 

The  length  of  the  vagina  is  ascertained,  in  the  erect  position,  by  the 
finger,  or  by  passing  the  straight  whalebone  stick  or  the  sound  up  behind 
the  cervix  to  the  limit  of  the  pouch,  and  marking  the  spot  where  it  touches 
the  symphysis  pubis.  Beyond  this  point  no  vaginal  pessary  should  descend. 
The  width  of  the  vagina  is,  of  course,  easily  ascertained  by  the  finger. 


362  MINOR    GYNECOLOGICAL    MANIPULATIONS. 

The  dilatability  and  contractility  of  the  vaginal  walls  is  an  important 
point,  because  the  rule  for  all  j^essaries  acting  by  leverage,  indeed,  all 
which  do  not  act  only  by  their  size,  is  that  they  shall  not  dilate  the 
vagina  sufficiently  to  produce  tension,  or  to  cause  the  pessary  to  press 
into  the  tissues.  A  very  dilatable  vagina  with  lax  walls  will,  therefore,  re- 
quire and  permit  a  larger  pessary  than  a  canal  with  nonnally  contractile 
power,  such  as  the  healthy  vagina  possesses.  It  seldom  happens  that  a 
pessary,  which  is  to  act  on  the  lever  principle  alone,  need  be  larger  than 
three  inches  long  and  one  and  a  half  inch  wide. 

The  depth  and  width  of  the  posterior  vaginal  p)Oucli  after  replacement 
of  the  uterus  determines,  to  a  great  extent,  the  amount  of  the  curve  of  the 
■posterior  portion  of  the  pessary  (retroversion  only,  again)  and  the  proba- 
bility that  the  pessary  will  be  retained.  The  deeper  the  retro-cervical 
pouch,  the  easier  to  find  a  suitable  instrument.  The  shallower  the  pos- 
terior pouch,  the  more  difficult  to  find  a  pessary  which  will  retain  its 
proper  position,  and  do  its  duty  by  pressing  the  pouch  upward  and  the 
body  of  the  uterus  forward.  In  many  cases  the  posterior  vaginal  pouch 
requkes  elongating  by  mechanical  pressure  from  pessaries  until  it  has 
been  pushed  so  far  up  as  to  give  the  vaginal  pessaiy  a  purchase  on  the 
body  of  the  uterus.  This  may  be  done  either  by  changing  the  length 
and  curve  of  the  vaginal  pessary  from  time  to  time,  and  thus  gradually 
stretching  the  pouch  up  to  a  level  with  the  internal  os  behind,  or  by  sup- 
jDorters  connected  with  an  abdominal  bandage.  It  may  require  months  to 
obtain  this  result.  In  congenital  retroversion  of  an  anteflexed  uterus,  or 
congenital  shortness  of  the  vagina  and  intravaginal  portion  of  the  cervix 
(conditions  which  are  often  found  in  married  but  sterile  women,  and 
which  Emmet  believes  to  be  due  to  unappreciable  inflammatory  contrac- 
tion of  one  or  both  broad  ligaments),  this  deformity  of  the  posterior  pouch 
is  very  marked  and  exceedingly  difficult  to  change,  requiring,  at  times,  the 
aid  of  an  intra-uteiine  stem  as  a  handle  by  which  to  raise  up  the  uterus 
with  a  lever-pessary. 

In  no  case  should  the  uterine  arch  of  the  pessar)"-  be  so  sharply  curved 
as  to  press  directly  against  the  ceiwix  at  its  junction  with  the  vagina. 
The  uterine  curve  should  be  straight  upward,  not  forward  also,  and  the 
pressure  be  exerted  against  the  apex  of  the  posterior  vaginal  pouch.  The 
uterus  should  rest  against  the  posterior  curve  of  the  pessary  as  a  person 
rests  against  the  back  of  a  chair,  and  VlWJ  pressure  exerted  on  the  uterus 
should  proceed  from  the  whole  uterine  curve,  not  from  the  posterior  trans- 
verse bar  only. 

The  iceight,  size,  and  density  of  the  iderus  also  influence  the  selection  of 
the  pessary.  The  heavier  the  uterus,  the  larger  the  pessar}^  (within  proper 
limit),  and  the  thicker  its  branches  in  order  to  avoid  cutting  into  the  tis- 
sues. Besides,  in  retro-displacements  the  posterior  bar  of  the  pessary  may 
need  to  be  enlarged  by  addition  of  a  bulbous  expansion  (see  Fig.  198)  in 
order  to  avoid  the  erosion  and  cutting  of  the  pessary  into  the  posterior 
wall  of  the  heavy  uterus.  The  same  form  of  pessary  may  also  be  required 
in  cases  where  the  normal  density  and  firmness  of  the  uterine  tissue  has 


MAISTAGEMENT    OF    PESSARIES.  363 

become  so  much  impaired  as  to  allow  the  uterus  to  gradually  bend  over 
the  jDosterior  bar  of  the  slender  pessary,  as  though  there  were  a  joint  at 
that  spot.  This  latter  accident  is  a  source  of  gi'eat  annoyance  to  patient 
and  jDhysician,  and  may  tax  the  ingenuity  of  the  latter  greatly  before  a 
proper  supporter  is  found.  The  best  way  probably  is,  if  the  bulb  fails,  to 
construct  a  pessary  shaped  like  the  capital  letter  U,  in  the  centre  of  which 
the  uterus  rides  as  in  a  saddle.  The  posterior  bow  reaches  up  so  high 
that  the  j^oint  of  flexion  is  below  the  cross-bar.  The  difficulty  of  introduc- 
ing these  pessaries  is  the  objection  to  them  ;  it  may  often  be  overcome  by 
inserting  them  through  a  Sims  speculum. 

I  think  I  have  had  more  trouble  in  fitting  pessaries  to  retroflexed  uteri 
with  this  peculiar  joint-like  flabbiness  at  the  point  of  flexion,  especially  if 
the  cervix  also  was  short  and  the  posterior  vaginal  pouch  shallow,  than  in 
any  and  all  other  forms  of  uteric  displacement.  Here  the  Cutter  pessary 
(Fig.  209),  or  an  intra-uterine  stem  with  a  lever-jjessary,  have  at  times  an- 
swered the  purpose  ;  but  I  confess  to  having  been  completely  baffled  by 
several  of  these  obstinate  cases,  and  have  therefore  availed  myself  of  several 
favorable  opportunities  for  testing  Alexander's  method  of  opening  the  in- 
guinal canal  and  shortening  the  round  ligaments.  My  experience  with  this 
operation  is  so  far  confined  to  four  cases,  and  I  am  as  yet  unable  to  make 
a  j)Ositive  report  on  its  value. 

The  dimensions  and  length  of  the  intravaginal  portion  of  the  cervix 
should  be  noted,  because  a  large  cervix  requires  a  correspondingly  large 
pessary,  and  the  length  of  the  intravaginal  portion  determines  the  depth 
of  the  vaginal  pouch. 

The  presence  or  absence,  and  the  seat  of  tenderness  in  the  parametrium  or 
uterus  are  exceedingly  imj)ortant  points  in  deciding  upon  the  advisability 
of  introducing  a  pessary  at  all,  and  upon  the  variety,  shape,  and  size.  If 
there  is  any  evidence  of  acute  inflammation  of  uterus  or  adnexa,  the  pessary 
is  counter-indicated.  If  there  be  a  tumor  in  the  pelvis  due  to  chronic  cellu- 
litis or  peritonitis,  a  pessary  should  not  be  used,  because  it  is  of  no  service, 
the  uterus  being  fixed,  and  needing  no  support.  But  if  mere  localized 
tenderness  is  felt  in  the  vaginal  pouch,  without  any  appreciable  swelling, 
the  question  may  arise  whether  this  is  due  to  subacute  inflammation  or  to 
the  pressure  of  the  displaced  iiterus  ;  if  the  former,  the  pessary  will  do 
harm,  if  the  latter  (and  replacement  of  the  uterus  may  decide  the  question) 
of  course  the  pessary  should  be  applied.  If  the  tenderness  be  very  slight, 
the  pessary  may  be  so  chosen  or  cLanged  as  to  avoid  pressing  on  this  spot ; 
this  is  frequently  done  with  retro-uterine  tenderness,  the  exact  nature  of 
which  is  not  clear.  If  the  uterus  is  tender  to  the  touch,  as  it  verj'  often  is 
in  displacements  (ante-  and  retro-),  the  question  comes  up  whether  this 
tenderness  is  not  due  to  the  congestion  produced  by  the  displacement. 
This  is  very  frequently  the  case,  and  the  reposition  and  retention  of  the 
uterus  by  a  pessary  is  therefore  called  for.  The  tenderness  will  then  soon 
disappear.  Often,  however,  the  tenderness  is  so  great  (chiefly  in  retro- 
displacements)  that  preparatory  treatment  is  requii-ed  before  the  pressm*e 
of  the  pessary  can  be  borne. 


364  MIXOR    GYNECOLOGICAL    MANIPULATIONS. 

The  degree  of  laceration  of  the  perineum,  or  of  support  afforded  by  that 
body,  f  not  torn,  is  important  in  selecting  a  jDessary  ;  for  a  larger  instru- 
ment is  required  if  the  normal  support  of  the  perineum  is  wanting,  or  the 
Yao-inal  orifice  gapes.  It  is  not  because  the  pessarj'  rests  upon  the  peri- 
neum, but  because  the  natural  \J  curve,  to  which  the  lever  pessary  con- 
forms, is  wanting  when  the  perineum  is  destroyed  or  relaxed.  It  fre- 
quently becomes  necessary  to  restore  that  body  before  a  pessary  of  a  size 
corresponding  to  the  undilated  vaginal  canal  can  be  retained.  A  larger 
instrument,  which  would  be  retained,  exerts  too  great  a  tension  on  the  va- 
ginal walls,  and  wiU  soon  give  pain  and  produce  ulceration.  If  an  opera- 
tion is  imj)racticable,  the  uterus  may  require  to  be  supported  by  a  pessai-y 
which  acts  through  its  size  or  by  expansion,  and  that  this  is  injurious  has 
abeady  been  pointed  out. 

The  amount  of  vaginal  secretion  will  influence  the  actual  placing  of  a 
pessary,  rather  more  than  its  shape  or  size.  If  there  is  a  profuse  vaginal 
leucon-hea,  particularly  if  the  discharge  is  discolored  and  is  seen  through 
the  speculum  to  proceed  from  a  maceration  or  abrasion  of  the  vaginal 
epithelium,  a  pessary  should  certainly  not  be  apjDlied.  The  cause  of  the 
discharge  must  be  removed,  in  the  manner  described  under  Applications  to 
the  Vagina,  before  it  would  be  wise  to  subject  the  mucous  membrane  to  the 
inevitable  irritation  of  a  pessary.  Besides,  a  profuse  chronic  leucorrhea  is 
a  probable  indication  of  a  relaxed  flabby  vagina,  or  of  a  uterine  catarrh. 

The  tension  of  the  anterior  vaginal  wall  icith  the  bladder  will  affect  the 
selection  of  a  pessary,  since  if  that  part  is  relaxed  or  prolapsed  (cystocele), 
a  peculiar  form  of  pessary  is  required,  which  will  not  only  supjjort  the 
uterus,  but  also  the  anterior  vaginal  wall.  Should  the  position  of  the 
uterus  be  normal,  the  cystocele  alone  requires  to  be  supported,  and  for 
this  purpose  a  special  variety  of  pessaries  is  employed. 

The  presence  of  a  prolap)sed  ovary  at  the  bottom  of  Douglas'  pouch,  will 
often  greatly  interfere  with  the  wearing  of  a  pessary.  Momentary  press- 
ure on  the  ovary  with  the  finger  gives  acute  pain  if  the  organ  is  congested 
or  inflamed  ;  but  even  the  normal  prolapsed  ovary  will  soon  resent  the 
steady  pressure  of  a  pessary  and  call  for  its  removal.  The  constant, 
dull,  aching  pain  in  the  back  and  hips  will  then  depend  on  this  pressure. 
I  recently  saw  a  case  where  the  ovary  was  latero-prolapsed  and  lay  to  the 
left  of  the  cervix  ;  it  appeared  to  be  fixed  by  adhesions.  As  the  patient 
had  an  acute  retroflexion,  I  deemed  a  lever  pessary  necessary  and  intro- 
duced one  after  replacing  the  uterus.  The  pessary  did  very  well  so  far  as 
the  uterus  was  concerned,  but  still  the  patient  complained  of  a  dull  ache 
in  the  left  hip,  which  soon  became  unbearable.  The  cause  was  found  in 
the  steady  pressure  exerted  by  the  pessary  on  the  prolapsed  and  adherent 
ovary,  a  pressure  which  had  not  been  exercised  when  the  pessary  was  first 
introduced.  The  gradual  adaptation  of  the  parts  to  the  pessary  had 
trought  it  in  contact  with  the  ovary.  As  the  latter  could  not  be  rejjlaced, 
and  I  could  contiive  no  pessary  which  would  avoid  the  ovary  and  at  the 
same  time  support  the  retroflexed  uterus  (which,  by  the  way,  was  not 
easy)  I  was,  after  several  ineffectual  trials,  forced  to  let  the  patient  do 


INTRODUCTION    AND    SUPERVISION    OF    PESSARIES.  365 

without  any  pessaiy.  She  preferred  to  keep  her  retroflexion,  which  gave 
her  far  les3  discomfort  than  the  pressure  of  the  pessary  on  the  ovary. 
Perhaps  a  greater  amount  of  mechanical  ingenuity  might  have  led  to  the 
construction  of  a  suitable  instrument,  and  here  again  it  is  the  special  in- 
genuity of  the  physician  which  enables  him  to  conquer  difficulties,  unsui*- 
mountable  by  others  less  dexterous.  Peculiar  shapes  must  be  given  to 
the  pessaries  so  as  to  avoid  pressing  on  the  ovary  and  still  support  the 
uterus.  Or  the  posterior  crossbar  of  a  retroversion  pessaiy  is  made  very 
broad  or  very  thick,  so  as  to  put  the  pouch  to  the  stretch  and  fill  it  out, 
and  thus  prevent  the  ovaries  from  descending.  Or  the  central  portion  of 
the  crossbar  is  beveUed  out  so  as  to  remove  pressure  from  an  ovary  situ- 
ated at  the  bottom  of  Douglas'  pouch. 

In  many  cases  the  vagina  will  gradually  adapt  itself  to  the  size  and 
shape  of  the  pessary,  and  I  have  spoken  of  cases  where  this  is  desired. 
But  these  cases  are  the  exception,  although  they  frec[uently  occur.  The 
rule  is  that  the  pessary  should  be  carefully  adjusted  as  regards  size  and 
shape  to  the  dimensions  and  curves  of  that  particular  vagina  ;  and  that  the 
size  and  shape  should  be  altered  whenever  a  change  in  the  vagina  re- 
quires it. 

It  will  be  seen  that  many  of  the  above  remarks  apply  chiefly  to  pessa- 
ries for  retro-disj)lacements. 

General  Fades  for  the  Introduction  and  Supervision  of  Pessaries. 

The  most  important  rule  unquestionably  is,  always  to  replace  a  dislo- 
cated uterus  before  attemj^ting  to  select  or  introduce  a  pessary.  Only 
when  the  uterus  is  replaced  can  the  length,  size,  and  shape  of  the  vaginal 
canal  be  correctly  estimated,  and  the  corresponding  properties  of  the  pes- 
sary be  imparted  to  it. 

This  rule  applies  only  to  retro- displacements  and  prolapsus.  An  ante- 
verted  or  anteflexed  uterus  need  not  be  replaced  before  applying  a  pessary, 
because,  in  these  disi^lacements,  no  rectification  of  position  or  cure  is  ex- 
pected or  attainable  by  a  pessary,  the  only  object  of  which  is  to  sujDport 
the  displaced  fundus  until  its  natui'al  supports,  the  utero-sacral  hgaments 
and  the  vaginal  column,  can  regain  their  tone. 

A  second  precaution,  never  to  be  overlooked,  is  not  to  leave  a  pessary 
in  the  vagina  which  is  so  tight  that  the  finger  cannot  be  passed  between  it 
and  the  vaginal  wall.  If  the  vagina  is  put  to  the  stretch  between  the  .bars 
of  the  pessary,  the  latter  is  too  large  and  wiU  infallibly  sooner  or  later  cut 
into  the  tissues.  Before  being  introduced,  every  pessary  should  be  dipj^ed 
in  warm  water  and  then  thoroughly  covered  with  vaseline,  oil,  glycerine, 
or  soap.  Its  introduction  is  greatly  facilitated  by  this  practice.  If  it  is  a 
complex  instrument  it  may  be  well  to  apply  a  carbolized  ointment  to  pre- 
vent its  becoming  rapidly  offensive. 

A  pessary  having  been  fitted  according  to  the  directions  above  given 
(the  method  of  introducing  pessaries  will  be  described  with  each  instni- 
ment),  it  is  important  to  ascertain  whether  it  really  fits  the  patient  under 
the  circumstances  when  she  is  most  hkely  to  need  its  support,  viz.,  in  the 


366  MINOR    GYIN-ECOLOGICAL    MANIPULATIONS. 

erect  position.  Every  patient  who  laas  just  had  a  pessary  introduced, 
should  therefore  be  examined  standing,  and  told  to  bear  down,  crouch,  or 
stoop,  in  order  that  the  finger  in  the  vagina  may  learn  whether  the  pessary 
withstands  the  pressure  and  weight  which  the  superincumbent  viscera  and 
the  necessities  of  daily  life,  or  the  patient's  occuj)ation  will  exert  upon  it. 
Only  by  this  erect  examination  can  the  physician  actually  tell  whether  he 
has  succeeded  in  selecting  a  perfectly  suitable  instrument.  Not  only  at 
the  first  visit,  but  when  the  patient  calls  again,  at  regular  intervals  to  have 
the  pessary  inspected,  should  this  examination  in  the  erect  position  be  re- 
peated. Even  when  it  is  desirable  to  move  the  instrument  the  patient 
need  not  he  down,  which  is  necessary  only  when  the  utems  is  to  be  re- 
placed or  the  old  or  a  new  pessary  introduced. 

The  patient  should  be  directed  to  go  about  her  usual  occupations,  to 
walk,  carry  burdens,  in  fact  to  put  the  pessary  thoroughly  to  the  test  (pro- 
vided, of  course,  her  general  health  and  the  tenderness  of  the  parts  per- 
mit), and  to  return  in  several  days,  certainly  within  a  week,  in  order  to 
have  it  looked  after  and  ai:iy  displacement  rectified,  or  a  new  one  intro- 
duced, if  necessary.  The  patient  should  be  told  that  she  is  wearing  a  pes- 
sary and  also  how  to  remove  it,  which  must  invariably  be  done  at  once  if 
it  gives  pain.  A  well-fitting  pessary  should  never  give  jDain,  rmless  the  rule 
regarding  uterine  or  para-uterine  tenderness  has  been  disregarded.  A 
rule  without  exception,  therefore,  is  that  no  pessary  should  be  worn  which 
gives  pain,  and  that  every  such  pessary  should  be  at  once  removed,  as  soon 
as  the  seat  and  continuance  of  the  pain  shows  that  it  is  caused  by  the 
pessary.  A  patient  should  be  able  to  walk,  ride,  dance,  use  the  sewing- 
machine,  in  fact  do  anything  she  could  do  in  health,  with  a  well-fitting 
pessary.  Should  she  not  be  able  to  do  all  these  things,  it  does  not  neces- 
sarily prove  that  the  pessary  does  not  fit  or  accomplish  its  purpose,  for  the 
inabihty  may  depend  on  general  debihty  or  upon  other  local  conditions 
than  the  displacement  (subinvolution,  hyperplasia,  laceration  of  cervix). 
Bat  as  the  object  of  the  pessary  is  to  enable  the  patient  to  go  about  her 
daily  duties,  if  necessary  earn  her  bread,  it  should  be  the  endeavor  of  the 
physician  to  accomplish  this  ;  therefore,  if  the  first  effort  and  the  first 
pessary  are  not  successful,  even  though  it  appears  to  fit,  another  and  still 
another  should  be  tried  until  the  proper  one  is  found  or  the  attempt  is 
abandoned. 

It  has  ah-eady  been  stated  that  a  well-fitting  pessary  should  give  no 
pain ;  but  more  than  this,  it  should  not  even  cause  discomfort ;  the  jDatient 
should  not  be  made  aware,  by  any  physical  sign,  that  she  is  wearing  such 
a  thing  ;  and  still  moi-e,  it  should  give  her  the  relief  from  pain  and  distress 
for  which  the  instrument  was  introduced.  This  relief  may  not  be  instan- 
taneous, it  may  even  be  delayed  for  several  days,  until  the  parts  have  ac- 
commodated themselves  to  the  instrument ;  but  if  her  symptoms  were  due 
to  the  displacement,  and  the  supporter  relieves  that  displacement,  the 
symptoms  mast  inevitably  disaj)pear  sooner  or  later.  If  they  do  not,  then, 
in  all  probability,  some  other  affection  is  the  cause  of  suffering. 

Another  reason  for  informing  a  woman  that  she  is  wearing  a  pessary, 


USTTRODUCTION    AIS'D    SUPERYISIOIT    OF    PESSARIES.  367 

than  to  enable  lier  to  remove  it  if  it  gives  pain,  is  that  she  may  possibly 
not  return  as  directed,  and  go  on  for  years  without  knowing  that  she  is 
wearing  a  pessary,  until  finally  the  foreign  body  becomes  so  foreign  to  its 
surroundings  as  to  give  rise  to  ulceration,  even  perforation  of  rectum  or 
bladder,  and  to  a  profuse  sanio-purulent  offensive  discharge,  which  has  been 
taken  for  cancer.  Thus,  but  recently,  a  physician  in  Maryland  removed 
from  a  patient,  supposed  to  be  suffering  from  cancer  of  the  uterus,  a  Hodge 
pessary  which  had  been  introduced,  unknown  to  the  patient,  five  years  be- 
fore, and  had  worn  its  way  deep  into  the  vaginal  walls.  Dr.  Rodensteiu,  of 
New  York,  lately  met  with  a  similar  case,  also  of  sup^DOsed  cancer,  which 
he  found  to  depend  on  the  retention  of  a  large  round  hard-rubber  ring,  in- 
troduced thirteen  years  before  in  Ii-eland  for  prolapsus  uteri.  It  was  com- 
l^letely  surrounded  by  granulations.  In  both  these  cases  the  physicians 
had  told  the  patients  to  return,  but  not  that  a  pessary  had  been  intro- 
duced. Feeling  relieved,  the  patients  did  not  return,  and,  consequently, 
no  opportunity  was  given  the  physicians  to  remove  the  pessaries. 

But  the  patient  should  also  be  told  that  the  pessary  wdll  give  her  no 
pain,  that  she  will  not  be  conscious  of  wearing  it,  and  should  not  think 
about  it.  As  soon  as  she  is  conscious  of  wearing  anything  in  her  vagina 
there  is  something  wrong  which  needs  investigation. 

If  the  pessary  should  protrude  from  the  vulva,  the  patient  should  be 
taught  to  push  it  back  gently.  A  pessary  may  fit  perfectly  when  first  in- 
troduced, but  become  displaced  by  exercise,  motion,  lifting,  defecation. 
The  converse  may  also  hold  good,  although  more  rarely,  that  a  j^essary 
which  at  fii'st  does  not  fit  perfectly,  after  a  few  days  has  shaped  the  vagina 
to  its  proportions  and  now  answers  very  well.  • 

It  is  advisable  to  keep  a  woman  in  bed,  or  on  a  lounge,  after  introduc- 
ing a  pessary,  only  when  it  is  intended  to  gradually  accustom  the  parts  to 
the  instrument,  or  when  the  parts  are  too  tender  to  endure  the  pressure 
exerted  by  the  pessary  when  the  latter  is  pushed  down  by  intra-abdominal 
pressure.  In  the  latter  case  it  will  generally  be  inadmissible  to  introduce 
any  hard  pessary,  and  the  jDarts  need  jjreparatory  toughening  by  cotton 
tampons  soaked  in  giycerole  of  alum  or  tannin.  This  preparatory  treat- 
ment may  occupy  several  weeks  or  longer,  daily  pledgets  being  introduced  ; 
the  posterior  cul-de-sac  may  be  very  usefully  elongated  in  the  same  manner. 

When  the  inability  to  wear  a  pessary  depends  upon  chronic  enlarge- 
ment of  the  lymphatic  glands  situated  in  the  pelvic  cellular  tissue,  or  on 
inflammatory  deposits  in  the  latter,  the  permanent  tamponade  of  the 
vagina  with  pledgets  of  cotton  soaked  in  iodoform  and  glycerine,  with 
Peruvian  balsam  to  correct  the  odor,  will  be  found  very  beneficial  in  pro- 
ducing absorption  of  the  infiltration  and  liberation  of  the  adherent  uterus, 
and  very  grateful  to  the  patient.  The  vagina  should  be  packed  pretty  full 
of  cotton  and  the  tampons  renewed  eveiy  thirty-six  to  forty-eight  hours, 
this  treatment  to  be  continued  for  weeks  or  months,  until  either  the 
uterus  is  replaceable  and  the  parametrium  will  tolerate  a  pessary,  or  until 
at  least  the  backache  and  sideache  are  reheved  and  the  patient  feels  well, 
even  though  her  uterus  is  still  displaced. 


8G8  3IIN0K    GYJSTECOLOGICAL    MANIPULATIONS. 

The  bowels  should  be  kept  soluble  ;  otherwise  the  pessary  is  liable  to 
be  disiDlaced.  The  loaded  rectum  weighs  down  on  the  pessary,  and  when 
the  mass  of  hard  feces  is  at  length  forced  down  by  a  brisk  cathartic,  it 
catches  in  the  posterior  crossbar  of  the  pessary  and  dislodges  it.  Even  a 
perfectly  fitting  pessary  will  be  displaced  in  this  manner.  I  have  fre- 
quently had  patients  return  to  me  with  their  pessary  in  their  pocket,  say- 
ing that  it  had  been  displaced,  and  had  come  away,  or  they  had  removed 
it  while  straining  during  defecation,  their  bowels  not  having  been  moved 
for  several  days  ;  and  yet  this  very  pessary  had  been  worn  for  months  be- 
fore, and  had  been  a  perfect  fit. 

Patients  with  retroversion  and  prolapsus  should  be  directed  to  assure 
the  proper  adjustment  of  the  pessary,  and  temporarily  reheve  the  down- 
ward and  backward  pressure  exerted  by  the  uterus  on  every  pessary,  by 
assuming  the  genu-pectoral  position,  and  expanding  the  vagina  with  air 
(as  desciibed  in  the  chapter  on  Reposition  of  the  Uterus,  see  Figs.  172  and 
173)  at  least  once  every  day.  The  best  time  is  on  retiring  at  night,  the 
erect  position  not  being  resumed  until  the  next  morning. 

Every  pessary,  to  a  certain  extent,  irritates  the  vagina,  and,  sooner  or 
later,  produces  a  discharge,  which  will  also  be  more  early  and  jDrofuse  if 
the  pessary  is  made  of  a  destructible  substance,  such  as  soft  rubber. 

Patients  should  therefore  be  told  to  take  cleansing  injections  of  soap- 
suds, or  tepid  water,  or  if  there  be  already  leucorrhea,  a  teasjDOonful  of 
alum-powder  or  sulphate  of  zinc  may  be  added  to  the  pint  of  water.  A 
hard-rubber  pessary  may  not  produce  a  discharge  for  several  months,  but 
when  it  does  it  is  well  to  remember  that  the  instrument  may  have  pro- 
duced an  abrasion  of  the  epithehum  at  some  spot,  which  calls  for  its 
removal.  If  the  discharge  of  a  woman  who  has  been  wearing  a  pessary 
for  some  time  becomes  greenish,  or  sanious,  the  chances  are  very  greatly 
in  favor  of  the  pessary  having  produced  an  abrasion,  and  the  patient  should 
be  informed  of  this  symptom.  All  pessaries,  even  those  of  hard,  smooth, 
impervious  material,  are  Hable,  in  course  of  time  (one  or  more  years),  to 
become  incrusted  by  the  deposit  on  their  surface  of  salts  from  the  vaginal 
secretion.  They  then  become  rough  and  irritating,  produce  abrasions, 
and  foul  discharge,  and  should  of  course  be  removed.  The  soft-rubber  pes- 
saries are  most  easily  changed,  and  become  discolored,  macerated,  and 
rough  often  after  a  few  weeks.  They  must,  therefore,  be  more  carefully 
watched,  and  more  frequently  removed  and  cleaned  than  those  made  of 
hard  rubber.  The  least  irritating  substance  undoubtedly  is  glass,  but  its 
brittleuess  prevents  other  pessaries  from  being  made  of  it  than  the  large 
rings  for  prolapsus. 

In  order  to  avoid  this  incrustation  and  abrasion,  and  to  assure  one's 
self  that  the  pessary  is  still  in  place  and  doing  good,  every  patient  wearing 
a  pessary,  no  matter  of  what  construction  or  material,  or  for  what  displace- 
ment, should  be  examined  from  time  to  time.  This  interval  with  soft  pes- 
saries should  not  exceed  two  weeks,  with  hard  instruments  one  or  two 
months.  Therefore,  always  tell  your  patient  that  you  wish  her  to  report 
every  month  or  two,  or  oftener,  so  long  as  she  is  wearing  the  pessary,  and 


ITfTRODUCTION    AISTD    SUPERVISION    OF    PESSARIES.  369 

give  her  to  understand  most  distinctly  the  reasons  for  this  request,  and 
the  risk  she  runs  if  she  fails  to  comiDly  with  it.  I  have  frequently  seen 
more  or  less  severe  ulceration  of  the  vagina  from  non-compliance  with  this 
direction. 

It  is  advisable,  therefore,  to  remove  every  pessary,  even  though  it  is  in 
place,  now  and  then,  inspect  the  vagina  through  a  speculum,  and,  if  sound, 
re-introduce  the  instrument  at  once.  The  finger  cannot  tell  that  there  is 
an  erosion,  unless  it  is  deep,  although  it  may  he  strongly  suspected  if  the 
finger  is  tinged  with  muco-purulent  matter  on  being  removed,  and  no  en- 
dotrachelitis  or  cervical  laceration  is  present.  I  have  repeatedly  found 
quite  large  superficial  erosions  behind  the  cervix  from  pressure  of  the 
crossbar,  when  no  pain  had  been  experienced.  Some  vaginae  no  doubt  be- 
come more  easil}'  eroded  than  others,  and  those  in  which  the  epithelium 
ajopears  most  tender  should  be  most  carefully  watched. 

The  failure  of  a  practitioner  to  thus  examine  with  a  speculum,  in 
spite  of  the  complaints  of  the  lady  that  she  had  an  offensive  sanious 
discharge  for  some  months  while  wearing  a  retroversion  pessary,  caused 
the  patient  finally  to  seek  other  advice,  and  I  found  a  large  erosion  which 
it  took  two  months  to  heal. 

A  jDessary  need  not,  as  a  rule,  be  removed  dui'ing  menstruation  ;  in- 
deed, it  is  precisely  at  that  time  when  the  uterus  is  gorged  with  blood  and 
heavier  than  usual,  that  a  support  is  required.  Care  should  merely  be 
taken  to  thoroughly  cleanse  the  vagina  by  injections  after  the  flow  has 
ceased.  Complicated  pessaries,  such  as  the  cup-and-hinge  anteversion 
pessaries  of  Thomas,  are  very  Hable  to  become  incrusted  with  menstrual 
blood,  which,  being  attached  to  the  inner  surface  of  the  cup,  is  not  reached 
by  the  injections  ;  they  thus  become  very  offensive,  and  I  have  frequently 
found  it  necessary  to  remove  such  instruments  after  each  menstruation, 
and  cleanse  them  thoroughly  before  re-introducing  them,  in  order  to  pre- 
vent erosion  of  the  vagina. 

A  pessary  needs  occasional  changing  even  when  it  has  done  well.  The 
shape  of  the  vagina  alters  in  course  of  time,  and  the  old  pessary  no  longer 
does  its  duty  as  well  as  when  first  inserted.  A  new  one,  appropriately 
shaped,  should  therefore  be  substituted. 

It  is  a  good  plan  also  to  remove  a  pessary  from  time  to  time  and  give 
the  parts  a  rest  of  a  few  days,  using  hot-water  injections  as  an  astringent 
in  the  meanwhile  ;  or  introducing  alum  or  tannin  tampons  for  several  days. 
If  no  evidence  whatever  exists  of  pressure  by  the  j)essary,  this  ride,  of 
course,  need  not  be  observed. 

Finally,  the  pessary  may  be  removed  after  a  variable  lapse  of  time,  in 
order  to  see  whether  a  cure  of  the  displacement  has  been  effected.  This 
time  varies  from  three  months  to  as  many  years.  A  cure  may  be  expected 
chiefly  in  retro-displacements  ;  in  prolapsus  of  the  uterus  and  vagina,  but 
rarely  if  the  displacement  was  of  long  standing.  Ante-displacements  are 
restored  by  but  one  pessary  with  which  I  am  acquainted,  Gehrung's,  for  it 
gradually  retroverts  the  uterus. 

Prolapsus    uteri    may    be  cured  uninteutionallv  by  a  pessary,  which 

24: 


370  MINOR    GYNECOLOGICAL    MANIPULATIONS. 

has  been  allowed  to  remain  so  long  that  it  has  produced  ulceration  extend- 
ing over  more  or  less  of  the  vaginal  vault.  When  the  ulceration  heals, 
the  uterus  and  vagina  are  retained  by  the  resulting  cicatrices.  Such  a 
case  recently  came  under  my  notice,  a  round  glass  disk  having  been  re- 
tained for  five  years. 

If  a  pessary  has  become  fastened  in  the  vagina  by  granulations,  and  is 
covered  by  vaginal  tissue,  it  may  be  very  difficult  to  remove.  If  a  ring- 
shaped  pessary,  it  may  lie  in  a  canal  to  v^^hich  there  is  no  access,  except  by 
cutting  thi'ough  the  overlapping  tissue  at  one  spot,  clipping  the  branch 
of  the  pessary  with  strong  nippers  or  bone  forceps,  or  dividing  it  with  a 
chain-saw,  and  then  seizing  it  firmly  in  a  forceps,  withdrawing  it  with 
a  rotary  motion  until  the  opposite  part  of  the  pessary  arrives  at  the 
opening  ;  this  is  also  clipped  and  each  half  of  the  pessary  then  withdrawn 
separately. 

Sexual  intercourse  is  not  prohibited  by  the  presence  of  a  pessary.  In- 
deed, if  this  were  so,  how  could  women,  sterile  through  uterine  displace- 
ment, be  cured  of  their  sterility  ?  Of  course,  I  mean  pessaries  which  do 
not  obstruct  the  vagina  so  as  to  preveut  intromission  and  the  entrance  of 
the  spermatozoa  into  the  cervical  canal.  Such  are  those  chiefly  used  for 
anterior  and  retro-displacements.  Sterility  due  to  displacement  is  often 
cured  by  wearing  such  a  pessary.  A  certain  amount  of  caution  on  the  part 
of  the  husband  is  of  course  advisable,  in  order  that  the  pessary  may  not  be 
dislodged  or  the  male  organ  or  female  parts  injured. 

After  the  removal  of  a  pessary,  cleansing  or  astringent  injections  may 
be  required  for  a  few  days  ;  or  the  hot  vaginal  bath  to  preserve  and  pro- 
mote the  contractility  of  the  tissues. 

An  opinion  as  to  the  permanency  of  the  replacement  of  the  uterus  by 
the  pessary  after  removal  of  the  latter  should  be  guarded,  since  the  uterus 
may  remain  replaced  for  a  few  minutes,  hours,  even  days,  and  then  on  any 
more  than  iisual  exertion  or  strain  by  the  patient  return  to  its  former  dis- 
placed position.  After  removing  a  pessary  permanently,  it  is  therefore  always 
best  to  direct  the  patient  to  call  again  in  a  week  or  thereabouts,  when  an 
examination  will  reveal  whether  she  is  cured  of  her  displacement  or  not. 

In  concluding  these  remarks  on  the  general  and  special  rules  for  the 
application  of  pessaries,  I  will  merely  repeat  what  probably  has  akeady 
become  sufficiently  apparent,  viz.  :  that  the  mere  introduction  of  a  pessary 
by  no  means  concludes  the  connection  of  physician  and  patient  for  that 
particular  affection.  The  patient  should  be  informed  that  the  proper  fit- 
ting and  supervision  of  a  pessary  requires  a  certain  number  of  interviews  ; 
that  a  different  size  or  shape  may  be  called  for  sooner  or  later  ;  that  only 
a  careful  watch  over  the  pessary  will  prevent  its  doing  injury  ;  and  that, 
finally,  the  ciu^e  of  a  displacement  of  the  uterus  is  a  tedious  and  difficult 
matter,  and  well  worth  the  trouble,  attention,  and  expense  the  patient  is 
obliged  to  devote  to  it.  All  these  particulars  are  necessary,  since  many 
patients  think  that  all  they  need  do  to  be  cured  of  their  displacement  is  to 
have  a  pessary  introduced,  and  then  go  about  their  business.  The  danger 
and  uselessness  of  such  a  coui'se  have  been  repeatedly  pointed  out. 


PESSARIES  FOR  Aj^TE-DISPLACEMEISTTS  OF  THE  UTERUS.        37l 


a.  Pessaries  for  Ante-displacements  of  the   Uterus. 

Pessaries  for  the  support  of  the  ante-displaced  fundus  uteri  generally 
possess  one  mechanism  which  inserts  itself  between  the  symphysis  pubis 
and  the  uterus,  and  another  which  is  intended  to  draw  the  cervix  forward' 
and  thus  tilt  the  fundus  backward.  This  is  the  only  correct  principle 
upon  which  anteversion  pessaries  should  be  constructed.  This  traction 
may  be  exerted  either  by  a  ring  encircling  the  cervix,  or  by  the  transverse 
or  upward  expansion  of  the  anterior  vaginal  pouch.  The  ring  which  en- 
circles the  cervix  should  not  be  so  large  as  to  distend  the  posterior  pouch 
of  the  vagina  ;  for  if  it  does,  it  wiU  draw  the  cervix  backward,  tilt  the 
fundus  still  more  forward,  and  thus  counteract  the  supporting  effect  of  the 
]3essary. 

Pessaries  which  act  in  this  faulty  manner  are  those  of  Thomas,  seen  in 
Fig.  186,  the  so-called  "  buckle  pessary ; "  that  of  Hitchcock,  an  elastic 
ring  covered  with  soft  rubber,  lately  also  made  of  hard  rubber  (Fig.  187), 
and  to  a  less  extent  that  of  Graily  Hewitt  (Fig.  191).  Theoretically  the 
best  anteversion  pessary,  in  my  opinion,  is  that  of  Gehrung  (Fig.  182).  A 
very  good  pessary,  also  acting  on  the  correct  principle  of  distending  and 
elevating  only  the  anterior  pouch,  is  the  "  cup-pessary  "  of  Thomas  (Fig. 
189).  *Any  pessary  which  supports  the  uterus  in  any  way,  such  as  a  simple 
elastic  ring  (Fig.  208),  or  a  perforated  block  of  soft  or  hard  rubber,  will 
also  give  relief  in  anteversion.  But  these  latter  instruments  will  act 
only  by  lifting  up  the  whole  uterus,  which  I  have  already  stated  to  be 
usually  somewhat  lower  in  the  pelvis  than  normally,  in  anteversion.  The 
fundus  alone  is  lifted  up  only  by  pessaries  properly  constructed  for  that 
purpose. 

The  difference  between  anteversion  and  anteflexion  pessaries  is  but 
slight.  Those  for  anteflexion,  being  required  to  straighten  the  uterus  as 
well  as  to  lift  up  the  whole  organ,  need  to  possess  a  higher  anterior  bar 
than  in  anteversion,  and  a  ring  to  draw  the  cervix  forward,  for  there  is  gen- 
erally some  anteversion  with  the  flexion.  For  this  purpose  Thomas'  closed 
cup-pessary  (Fig.  188),  and  Graily  Hewitt's  cradle-pessary  (Fig.  191),  have 
best  satisfied  me.  But  it  may  be  as  well  to  understand  that  no  vaginal 
support  will  straighten  an  anteflexed  uterus.  Only  an  intra-uterine  stem 
will  accomplish  this  perfectly.  The  benefit  derived  from  pessaries  in  ante- 
flexion probably  depends  mostly  upon  the  relief  of  the  anteversion.  But 
I  believe  that  the  constant  pressure  of  the  smooth  wall  of  Thomas'  cup- 
pessary  against  the  flexed  anterior  wall  may,  after  a  while,  somewhat  miti- 
gate the  acuteness  of  the  angle.  A  cure  of  an  anteflexion  is  not  to  be  ex- 
pected by  a  vaginal  support. 

One  of  the  best  anteversion  pessaries,  therefore,  in  my  opinion,  is  that 
of  Gehrung,  the  "  double  horseshoe  "  pessary.  It  is  simply  a  single-lever 
Hodge  pessary  bent  upon  itself,  one  bar  being  slightly  longer  than  the 
other.  This  pessary  rests  on  the  floor  of  the  pelvis  by  its  two  lateral 
curves  R  and  L,  the  superior  and  inferior  arches  S  and  I  being  in  the 


372 


mijstoe  gynecological  manipulations. 


^ 


\ 


B. 


anterior  vaginal  poncli  between  fundus  nteri  and  sympLysis  pubis.  Ob- 
viously, there  can  be  no  anteversion  when  this  pessary  is  j)i*operly  fitted. 
Gehrung  himself  describes  the  pessary  as  resting  Avith  its  whole  lower 
arch  on  the  floor  of  the  pelvis,  and  the  uterus  reclining  against  its  superior 
curve,  as  shown  in  the  cut  taken  from  Gehrung's  article  on  "  Mechanical 
Gynecology."  But  my  experience  is  that  the  pessary  rests,  as  ah-eady  de- 
scribed, on  the  curves  R  and  L,  and  therefore  stands  more  upright,  where- 
by it  elevates  the  anterior  pouch  still 
/"  "~''\      more.     The  uterus  then  leans  against 

the  whole  superior  arch,  not  within  it, 
as  Gehrung  draws  it.  By  this  position, 
coition  is  rendered  possible,  which  was 
not  practicable  in  the  other  position  tin- 
less  the  largest  size  was  used.  But  the 
expansion  of  the  vagina  being  lateral, 
and  the  peculiar  shape  of  the  horseshoe 
also  giving  the  pessary  the  greatest  sep- 
aration of  the  bars  in  a  transverse  di- 
rection, there  is  no  obstacle  to  the  im- 
missio  penis,  which  would  exist  if  the 
pessary  lay  as  its  inventor  describes  ifc. 
This  modification  of  the  author's  direc- 
tions was  not  sought  at  first,  although 
I  recognized  the  disadvantage  as  re- 
gards coition,  but  established  itself  ; 
for  I  found  that  gradually  the  pessary 
always  assumed  the  position  which  I 
now  give  it.  Seeing  that  the  coition  difficulty  was  thus  removed,  and  the 
fundus  thoroughly  supported,  I  have  since  introduced  it  in  this  manner. 
The  point  of  support  of  this  pessary  is  the  posterior  vaginal  wall  and  per- 
ineal body,  its  resting-place  the  symphysis  pubis,  against  which  the  infe- 
rior arch  presses.  The  superior  arch  sujDports  the  uterus.  No  part  of  the 
pessary  extends  into  the  posterior  part  of  the  vagina. 

The  construction  of  the  pessary  is  apparent  from  the  cut.  It  will  be 
noticed  that  the  superior  arch  jDrojects  in  front  over  the  inferior.  The  ele- 
vation of  the  fundus  is  increased  by  this  projection.  By  separating  the 
lateral  branches  its  retentive  power  is  increased  (Fig.  184). 

Gehrung's  pessary  comes  in  five  different  sizes,  the  smallest  of  which 
can  be  introduced  into  any  virgin  with  normal  hymeneal  orifice  ;  the  lar- 
gest is  used  for  very  large  vaginse,  prolapsus,  and  cystocele. 

The  manner  of  introducing  it  is  as  follows :  The  pessary  is  placed  on 
the  table,  or  the  palm  of  the  left  hand,  Avith  the  superior  convex  arch  S 
downward,  the  inferior  arch  I  above,  the  open  part  (curves  R  and  L)  point- 
ing toward  you  ;  seize  curve  L  with  thumb  and  forefinger  of  your  right 
hand,  separate  the  labia  with  the  same  fingers  of  the  left  hand,  the  pa- 
tient being  in  the  dorsal  position,  and  insert  curve  K  into  the  vagina  to 
the  right  of  the  patient,  until  three-fourths  of  the  instrument  is  buried 


Fig.  182. — Gehrung's  Anteversion  Pessary. 
Anteversion  ;  B,  Ketroversion  (G-ehmng). 


A, 


PESSARIES  FOR  ANTE-DISPLACEMENTS  OF  THE  UTERUS. 


373 


■within,  tlien  rotate  it  on  point  E  as  on  a  pivot,  by  pushing  curve  L  toward 
the  fourchette  and  the  left  side  of  the  patient,  so  that  at  the  same  time  the 
curve  L  sHps  into  the  vagina,  the  arch  S  will  turn  upward  under  the  body 
of  the  uterus,  and  the  arch  I  downward  to  the  os  pubis.  Then  press  the 
uterus  gently  up  with  the  pessary,  and  see  that  the  curves  K  and  L  rest 
squarely  on  the  posterior  vaginal  wall. 

If  the  vagina  is  so  large,  and  its  walls  so  lax  that  the  pessary  seems  likely 
to  slip  down  or  out,  a  pledget  of  cotton,  soaked  in  glycerole  of  alum  or  tan- 
nin, may  be  placed  between  the 
bars  of  the  pessary  for  several 
days.  Or,  the  branches  of  the 
pessary  may  be  separated  a  little 
more,  so  as  to  distend  the  vagina 
laterally  still  more.  I  have  sev- 
eral times  seen  this  pessary  ele- 
vate the  uterus  so  Avell  as  actually 
to  retrovert  it  in  the  course  of  a 
few  weeks.  In  that  case,  it  should 
be  removed  for  a  few  days.  In 
several  instances  I  was  obliged 
to  remedy  the  retroversion  by  a 
lever-pessary. 

If  the  pessary  is  too  small,  or 
has  not  been  properly  adjusted, 
its  superior  (longer)  arch  may 
slip  behind  the  cervix,  which  or- 
gan is  then  found  between  the 
two  curves  of  the  double  horseshoe- 
its  object,  and  may  even,  give  pain 


Fig.  183. — Position  of  GehruTig's  Pessary  in  Antever- 
sion  and  Cystxioele  (P.  F.  M.). 


The  pessary  then,  of  course,  fails  in 
By  using  an  instrument  with  more 
widely  separated  lateral  branches,  this  accident  will  be  avoided. 

While  my  first  experience  led  me  to  pronounce  this  instrument  of 
Gehrung  the  best  one  for  anteversion,  I  regret  that  subsequent  more  ex- 
tended observation  has  not  confirmed  the  expectations  which  I  at  first  en- 
tertained. I  still  find  it  the  best  means  for  the  retention  of  a  large  cysto- 
cele  or  of  an  anteverted  uterus  when  the  vagina  is  capacious  and  a  large 
pessary  with  widely  spread  branches  can  be  used  ;  but  in  vaginae  of  mod- 
erate size,  and  with  the  smaller  pessaries,  I  have  found  it  to  be  almost  the 
rule  that  sooner  or  later,  generally  in  a  few  weeks,  the  pessary  turns  so  as 
to  i^resent  its  concavity  toward  one  side  or  the  other.  Repeated  replace- 
ment only  resulted  in  the  same  occurrence,  and  I  have  within  the  past 
year  reluctantly  lost  much  of  the  faith  I  formerly  had  in  the  pessary  for 
anteversion.  I  still  occasionally  use  it  for  that  purpose,  but  find  the  open 
cup-and-hinge  pessary  of  Thomas  much  more  efficient  and  reliable. 

The  anteversion  pessaries,  constructed  by  adding  a  movable  anterior 
bar  to  a  Hodge  lever-pessary,  aU  possess  the  same  defect,  that  the  posterior 
arch  stretches  the  posterior  vaginal  pouch  and  counteracts  the  upward 
action  of  the  movable  bar.     While  they  undoubtedly  elevate  the  fundus 


or 


UmOR    GYNECOLOGICAL    MANIPULATIOISrS. 


and  the  whole  uterus,  they  do  so  at  the  expense  of  a  considerable  dilata- 
tion of  the  vagina,  and  the  pressure  necessarily  exerted  by  the  anterior 
movable  bar  is  likely  to  produce  excoriation. 

In  retroversion  of  the  anteflexed  uterus  they  possibly  may  do  good,  al- 
though generally  the  posterior  pouch  is  too  shallow  to  give  the  pessary  a 
sufficient  purchase  to  hold  or  lift  up  the  fundus. 


Correct , 


Incorrect . 


0 


r-\ 


Fig.  184. — Diao^riim  Illustrating  Separation  of 
Lateral  Branches  of  Gehrung's  Pessary  to  Increase 
its  Retentive  Power  (Gehrung). 


Fig.  185 \\  ouJ  .\ -lid's  IV-^bJiy  for  Ret- 
roversion with  Anteflexion. 


The  anteversion  pessary,  shown  in  Fig.  186,  is  a  modification  of 
Hodge's  lever,  again  modified  by  Thomas,  and  is  inti-oduced  closed.  The 
patient  may  occupy  either  the  dorsal  or  lateral  recumbent  position.  The 
difficulty  about  this  pessary  is  that  the  length  of  the  movable  bar  ren- 
ders it  difficult  to  open  and  separate  it  when  the  j)essary  is  in  the  va- 
gina. This  is  done  by  passing  a  piece  of  taj)e  around  the  movable  bar, 
and  seizing  both  the  ends  with  the  right  hand  outside  of  the  vulva.  The 
left  hand  separates  the  labia,  and  the  pessary  is  introduced  closed  by  the 
right  hand,  with  the  upper  end  and  movable  bar  foremost.  As  soon  as 
the  arch  reaches  the  cervix,  the  left  index-finger  pushes  the  posterior  arch 
backward  and  upM'ard  under  and  behind  the  cervix,  while  simultaneously 
the  right  hand  seizes  the  tape,  and  by  it  pulls  the  movable  bar  forward  as 
far  as  it  will  go.  This  is  the  difficult  part  of  the  maneuvre,  as  the  tape  is 
liable  to  slip  ;  besides,  the  rapid  forcing  up  of  the  anterior  vaginal  wall 
by  the  movable  bar  gives  pain.     If  introduced  on  the  side,  the  pessary  is 

inserted  with  its  concave  surface  downward, 
and  passed  on  until  the  anterior  lip  of  the  cer- 
vix is  touched,  when  the  left  hand  (this  time) 
pulls  forward  the  bar  by  the  tape,  and  the 
right  index-finger  lifts  the  posterior  arch  of  the 
pessary  over  and  behind  the  cervix.  This  ma- 
neuvre will  be  fully  discussed  in  describing  the 
aiDplication  of  lever-pessaries.  The  uterus  now 
rides  between  the  posterior  arch  and  the  mov- 
able bar,  as  in  a  saddle,  or  as  though  sus- 
pended by  two  ropes.  This  pessary  is  removed  by  drawing  on  the  sub- 
pubic arch  with  the  index-finger,  when  the  buckle  will  fall  back  as  the 
posterior  arch  is  drawn  down,  and  the  pessary  is  removed  closed,  as  it  was 
introduced.  The  great  disadvantage  of  this  pessary  is  the  tendency  of  the 
movable  bar  to  be  displaced  backward  by  the  motion  of  the  anterior  vagi- 
nal wall  in  respiration,  and  varying  fulness  of  the  bladder.  The  cervix  is 
then  squeezed  between  the  movable  bar  and  the  posterior  arch,  and  may 


V-'AS^Vftw^ 


Fig.  186. — Thomas'  Anteversion 
(Buckle)  Pessary,  open.  The  cross- 
piece  is  movable  to  the  right  for  in- 
sertion. 


PESSAEIES  FOR  ANTE-DISPLACEMENTS  OF  THE  UTERUS.       375 


Fig.  187. — Hitchcock's  Antever- 
sion  Pessary. 


be  SO  severely  compressed  as  to  become  ulcerated,  and  give  rise  to  gi'eat 
pain.  A  rubber  band  has  been  attached  to  the  top  of  the  movable  bar  and 
the  anterior  pointed  curve,  to  draw  the  bar  forward,  and  prevent  its  dis- 
l^lacement ;  but  this  band  easily  decays,  and  becomes  offensive.  This  pes- 
sary is  but  little  used  now,  except  where  marked  anteversion  and  descensus 
are  combined. 

A  useful  pessary  (the  device  of  Thomas),  chiefly  when  the  vagina  is 
roomy  and  the  perineum  destroyed  or  flabby,  is  a  Hodge  single  lever  with 
a  fixed  or  movable  bar  attached  (similar  to  the  instruments  shown  in  Figs. 
185  and  186),  which  projects  under  the  pubic  arch,  as  a  means  of  fixing  the 
pessary,  while  the  upper  broad  bar  presses  up  the 
anterior  vaginal  wall.  It  is  introduced  closed  in 
the  back  or  lateral  position,  and  the  movable  bar 
and  posterior  arch  are  separated  by  a  tape  pi-e- 
cisely  as  in  the  foregoing  instrument.  It  has 
served  me  much  better  for  cystocele  than  for 
simple  anteversion,  and  is  less  liable  to  injure  the 
anterior  wall  than  the  buckle  instrument.  This 
instrument  is  removed  by  seizing  the  fixed,  broad  anterior  arch  and  draw- 
ing it  downward  and  sidewise  through  the  vaginal  orifice,  when  the  mov- 
able bar  is  tilted  backward,  and  the  pessary  is  withdrawn  closed. 

Hitchcock's  elastic  ring-pessaiy  is  made  of  watch-spring  covered  vnth 
soft  rubber,  with  a  cross-bow,  which  is  to  go  in  the  anterior  vaginal  pouch. 
It  does  good  service  in  relaxed  vaginae,  and  I  had  a  patient  wear  one  with 
great  comfort  during  the  summer's  sojourn  in  the  Adirondacks.  But  it 
has  the  disadvantage  of  all  elastic  spring  pessaries  in  that  it  keeps  the  va- 
ginal walls  on  a  constant  stretch,  and  thus  tends  to  weaken  them,  and  that 
its  soft  covering  is  liable  to  become  roughened  and  offensive.  Besides,  it 
distends  the  posterior  vaginal  pouch.  It  is  introduced  on  the  back  or  side 
by  simply  compressing  the  ring  and  allowing  it  to  expand  slowly  when 
within  the  vagina.  The  finger  then  pushes  it  into  place.  It  is  now  made 
of  hax'd  rubber,  and  thereby  loses  two  of  its  objections,  the  elasticity  and 
perishability. 

Of  pessaries  which  are  more  adapted  to  anteflexion  (any  of  the  above 

may  also  be  used  for  flexion),  those  of 
Thomas,  constructed  on  the  jDrinciiDle  of  the 
cup-pessary  or  with  a  long  movable  anterior 
bar,  are  the  best — at  least,  I  have  had  the 
most  experience  with  them,  and  like  them 
better  than  any  others.  The  pessaries 
shown  in  Figs.  188  to  190  work  on  the 
same  principle,  the  cervix  being  held  in  the 
closed  or  open  ring,  while  the  body  rests 
against  the  smooth  sheU  of  hard  rubber.  The  pessary  is  prevented  from 
turning  in  the  vagina  by  an  anterior  movable  bar  which  rests  against  the 
inner  surface  of  the  pubic  arch.  The  pessary  is  introduced  on  the  back  or 
side,  the  movable  bar  being  extended  (see  Fig.  189)  and  the  broad  top  of 


•?iiv- 


Fro.  188.— Thomas'  Closed  Cup  Ante- 
flexion Pessary,  with  Hinges  Sunk,  so  as 
to  Prevent  their  Indenting  the  Vatjinal 
WaU(P.  F.  M.). 


376 


illNOK    GYNECOLOGICAL    MANIPULATIOlSrS. 


the  sliell  being  inserted  sidewise  into  the  vagina  until  the  tip  touches  the 
cervix  (Fig,  190),  wlien  the  index-finger  quickly  pushes  the  posterior  seg- 
ment of  the  ring  backward,  and  the  hinged  arch  becomes  horizontal. 
Slight  adjustment  with  the  finger  fixes  the  cervix  in  the  cup  and  places 
the  movable  bar  along  the  anterior  wall.  In  the  pessary  with  open  cup 
simple  pressure  against  the  anterior  vaginal  pouch  with  the  top  of  the 
^cup,  the  direction  of  the  force  being  directed  from  the  hinges  slightly 
backward,  will  cause  the  hinges  to  revolve  and  the  movable  bar  to  approach 
the  floor  of  the  cup.  One  advantage  of  this  open  variety  is  the  non-com- 
pression of  the  cervix  in  the  ring.  But  I  have  found  it  chiefly  useful  in 
anteversion,  where  I  generally  use  it  in  preference  to  the  closed  ring  or 
any  other  pessary.  The  removal  is  easily  accomplished  by  hooking  the 
finger  into  the  movable  arch  and  gently  drawing  on  it,  when  the  hinges 
will  revolve  and  the  pessaiy  become  extended  as  it  is  withdrawn. 


Fig.  189. — Thomas'  Open  Cup  Anteversion  Pes- 
sary, as  Introduced  and  Kemoved,  with  Hinges 
Sunk  (P.  F.  M.). 


Fig.  190. — Thomas'  Open  Cup  Anteversion 
Pessary  in  Position  (P.  F.  M. ).  The  anterior 
vaginal  wall  in  this  cut  is  incorrectly  drawn. 


All  these  hinge  instruments  may  be  advantageously  inserted  through  a 
Sims  speculum,  and  their  exact  position  be  thus  seen.  Indeed,  if  the 
woman  is  a  pluripara,  the  pessary  can  generally  be  inserted  through  the 
speculum  in  a  closed  condition  and  be  thus  adjusted  by  the  fingei'. 

The  great  objection  to  all  these  complicated  hinge  and  sjDring  instru- 
ments is  that  they  very  readily  become  offensive,  and  indent  the  vagina. 
They,  therefore,  require  very  careful  watching,  and  special  cleanliness. 
The  hinges  particularly  are  liable  to  indent  the  posterior  wall.  To  avoid 
this  I  have  had  them  sunk,  as  shown  in  Figs.  188  and  189. 

Numerous  other  anteversion  and  anteflexion  pessaries  have  been  de- 
vised, chiefly  by  Dr.  Thomas,  also  by  Drs.  Fallen,  Beverley  Cole,  Jan- 
vrin,  Galabin,  Gervds,  etc.,  which  all  act  on  a  principle  similar  to  that  shown 
in  Fig.  190,  that  is,  by  directly  elevating  and  supj)orting  the  fundus  uteri. 
The  same  object  is  intended  by  Gehrung  in  his  anteflexion  pessary  con- 
structed on  the  principle  of  his  anteversion  instrument,  with  the  addition 
of  a  plate  connecting  the  branches  of  the  superior  arch.  It  is  introduced 
precisely  like  the  anteversion  pessary  ;  of  its  utility  I  have  no  experience. 

A  pessary  greatly  in  vogue  in  England,  and  also  somewhat  used  here,  is 


PESSARIES    FOR    RETRO-DISPLACEMENTS. 


377 


Graily  Hewitt's  anteversion  or  anteflexion  "cradle  "  pessary  (Fig.  191).  It 
is  introduced  sidewise,  and  as  soon  as  the  crossbar  or  the  apex  of  the 
curves  is  within  the  vagina  the  long  bar  is  pushed  behind  the  cervix,  and 
the  other  arch  rests  along  the  anterior  vaginal  wall.  The  uterus  then  rests 
against  the  apex  or  crossbar,  with  the  cervix  in  the  j)osterior  curve.  I 
formerly  used  this  pessary  quite  often,  but  began  to  discard  it  when  I  had 
met  with  several  instances  where  its  crossbar  had  deeply  indented  the 
vaginal  wall. 

Pessaries  which  are  built  to  conform  to  the  shape  of  the  vagina,  and 
fill  but  not  distend  the  canal,  are  those  of  Hurd  (hard-rubber),  Hoffmann 
(soft-rubber),  and  Trask-Page  (inflated  soft-rubber 
dumb-bell).  These  pessaries  are  supposed  to  sup- 
port the  uterus,  whether  its  fundus  be  ante-  or 
retro-displaced,  and  doubtless  do  so  satisfactorily 
in  many  cases.  In  the  Hurd  and  Hoffmann,  the 
cervix  fits  into  a  hole  in  the  centre  ;  with  the  Trask- 
Page,  one  end  is  before  and  one  behind  the  cervix. 
I  have  no  exjDerience  with  these  pessaries. 

I  have  not  exhausted  the  list  of  pessaries  for  an- 
terior displacement,  but  have  given  those  which  are 
most  practical  and  most  in  use.      The  ingenuity  of  the  practitioner  must 
help  him  to  devise  new  or  modify  old  ones,  to  suit  his  cases. 

There  are,  of  course,  various  sizes  of  all  these  pessaries  which  are  not 
classified,  and  therefore  cannot  be  designated.  As  a  mle,  three  sizes  are 
made  of  each  pessary,  one  for  virgins,  one  for  married  nulHparee,  and  one 
for  multiparous  women. 


Fig.  ini.— Graily  Hew- 
itt's Antertexion  Pessary 
with  Crossbar.  The  instru- 
ment is  also  made  without 
the  crossbar. 


b.  Pessaries  for  Eelro-displacements. 

Kearly  all  pessaries  for  retro-displacements  of  the  body  of  the  uterus 
are  constructed  on  the  same  principle,  that  of  the  double  lever,  the  short 
strongly  curved  arm  of  the  lever  being  behind  the  cervix  in  the  posterior 
vaginal  pouch,  the  long,  mildly  curved  arm  in  front  of  the  cervix  along  the 
anterior  vaginal  wall  (see  Figs.  192  and  193).     The  fulcrum  of  these  pes- 


PiG.  192. — Hodge's  Double  Lever  Retro- 
version Pessary. 


Fig.  193. 


-Albert  Smith's  Retroversion  Pessary,  Front  View 
(gentle  curve). 


saries  is  at  the  deepest  point  of  the  posterior  vaginal  wall,  where  the  canal 
curves  upward  toward  the  posterior  pouch.  It  is  not  a  fixed  fulcrum,  but 
changes  with  the  position  of  the  patient.  The  lever  principle  on  which 
these   pessaries   act  has   akeady  been  described.     It   is   the   only  truly 


378  MINOE    GYNECOLOGICAL    MAlSTIPULATIOlSrS. 

physical  law  observed  in  tlie  mechanical  support  of  the  uterus,  which  at 
the  same  time  corrects  the  displacement  and  attempts  to  cure  it  perma- 
nently. The  parent  instrument  of  this  variety  is  the  original  closed  double- 
lever  pessary  of  Hodge.  It  is  still  used  in  many  cases,  particularly  where 
the  vagina  is  large  and  roomy,  with  dilated  walls  and  patulous  orifice. 
The  broad  anterior  bar  of  the  f)essary  rests  against  the  pubic  bones,  and 
aids  its  retention.  In  this  case  the  fulcrum,  or  rather  resting-place,  is  also 
at  the  symphysis  pubis.  As  a  supporter  for  a  prolapsed  and  retroverted 
uterus,  this  broad  pessary  is  often  very  serviceable,  correcting  both  dis- 
placements. 

The  open  lever  pessary,  in  which  the  anterior  crossbar  is  wanting,  is 
no  longer  used,  because  the  two  points  are  liable  to  injure  the  anterior 
vaginal  wall. 

The  Hodge  pessary  is  liable  to  turn  in  the  vagina,  so  as  to  He  diag- 
onally or  transversely.     To  obviate  this  Dr.  Albert  H.  Smith,  of  Philadel- 
phia, modified  the  original  Hodge  by  lengthening  it,  to  conform  more  to 
the  shape  of  the  vaginal  canal,  and  by  making  the  an- 
terior arch  more  pointed,  so  as  to  resemble  a  beak.    This 
pointed  extremity  reaches  quite  or  almost  to  the  pubic 
arch,  but  never  under  or  beyond  it.     A  Smith  pessary, 
which  projects  beyond  the  pubic  bones,  is  too  long  or 
has  slipped  down  from  behind  the  cervix.     The  Albert 
Smith  pessary  is  now  the  variety  most  commonly  used, 
and    has,   to    a  great    extent,   supplanted    the    original 
i        Hodge.    It  certainly  is  adapted  to  the  greatest  number  of 
''^^'\^^y         cases.     The   Smith  pessary  is  made  in  many  different 
Via.  194.— Different    sizcs  and  curvcs,  too  uumerous  for  description.     A  use- 
AibJrt  sLith^^pefs^    f^  modification  of  it  is  that  where  the  side-bars  at  the 
ries  (P.  F.  M.).  sliort  curve  are  slightly  more  separated  instead  of  run- 

ning jDarallel  to  a  point.  In  relaxation  of  the  posterior  vaginal  wall,  and 
short,  but  capacious  vaginse,  this  modification,  by  which  the  pessary  is 
somewhat  shortened,  increases  its  retentive  power.  In  some  of  these 
pessaries,  the  anterior  beak  is  more  sharply  bent  downward  so  as  not  to 
impinge  against  the  symphysis  pubis.  While  the  urethra  is  spared  by  this 
change,  the  pessary  is  rather  more  liable  to  escape  through  the  vulvar  cleft, 
and  may  interfere  with  coition. 

Another  less  known  and  therefore  less  popular  modification  is  that 
known  as  Sims',  the  peculiarity  of  this  pessary  being  that  it  is  more  narrow 
than  the  Hodge,  but  of  equal  breadth  at  both  ends.  It  answers  very  well 
in  cases  where  the  greater  breadth  of  the  Albert  Smith  or  Hoclge  distends 
the  vagina  too  much.' 

Another  excellent  modification,  chiefly  useful  in  cases  of  shallow  pos- 
terior pouch,  is  that  of  Emmet ;  it  is  less  curved,  flatter  than  the  Smith 
(very  similar  to  the  variety  shown  in  Fig,  193),  and  serves  as  the  basis 
from  which  Emmet  models  the  various  shapes  he  considers  necessary. 
He  has  had  six  sizes  made,  and  finds  them  to  answer,  with  minor  modifica- 
tions, for  the  large  majority  of  cases.     It  possesses  the  great  advantage  of 


PESSARIES    FOR    RETRO-DISPLACEMENTS. 


379 


not  forcing  the  posterior  vaginal  poucli  too  far  upward,  and  not  pressing 
too  firmly  against  the  posterior  surface  of  the  uterus  so  as  to  retroflex  it. 
It  is  also  a  good  instrument  for  slight  descensus  of  the  uterus.  I  have 
found  many  patients  derive  comfort  from  it,  in  whom  the  Smith  pessary 
proved  too  powerful  a  corrective.  A  similar  pessary  is  the  oval  hard-rubber 
ring  of  Hewitt,  the  lever  action  of  which,  however,  is  but  slight. 


S«>A\« 


Fig.  195. — Hewitt's  Ketroversion  Pessary. 


P.H.SO 


Fig.  196. — Gehrung's  Modification  of  Albert  Smith'; 
Pessari'. 


A  very  excellent  modification,  which,  may  decidedly  be  called  an  im- 
provement, is  that  shown  in  Fig.  196.  It  consists,  as  is  seen,  in  a  central 
depression  of  the  upper  curve,  in  which  the  body  of  the  uterus  rests  and 
by  which  the  pessary  is  prevented  from  slipping  sidewise,  as  readily  hap- 
pens with  the  ordinary  round  curve.  Another  advantage  is  the  higher 
lateral  tension  of  the  posterior  pouch,  whereby  pressure  is  taken  from  the 
centre  of  the  pouch,  and  the  prolapse  of  the  ovaries  in  Douglas'  pouch  is 
rendered  less  likely.  An  objection  is  the  pressure  of  the  two  lateral  horns 
of  the  posterior  curve,  which  may,  in  course  of  time,  give  pain,  and  pro- 
duce soreness,  especially  if  one  or  the  other  broad  ligament  is  tender  or 
contracted. 

For  the  purpose  of  distending  and  fiUing  the  posterior  vaginal  pouch, 
and  preventing  prolapse  of  the  ovaries,  Thomas  has  changed  the  slender 
posterior  bar  of  the  Smith  pessary  into  a  thick  bulb  (Fig.  197),  and  has 
at  the  same  time  lengthened  and  narrowed 
the  pessary.  The  addition  of  the  bulb  is 
an  advantage  ;  the  lengthening  and  narrow- 
ing, however,  diminish  its  chances  of  reten- 
tion. These  bulb-pessaries  are  now  made 
hollow  and  light,  being  cast  in  a  mould,  but 
cannot  be  heated  and  changed,  except  very 
slightly  in  their  long  diameter.  Formerly 
they  were  solid,  the  bulb  being  a  separate 
piece,  and  could  not  be  altered  at  all.  I 
have  had  them  made  to  order  for  special  cases,  shortening  and  widening 
the  lateral  bars,  and  have  then  found  this  variety  very  useful,  especially  in 
cases  of  retroflexion  of  a  flabby  uterus,  where  the  body  always  curled  back- 
ward over  the  slender  posterior  bar  of  the  Smith  pessary  ;  besides,  in  ova- 
rian prolapse.  These  pessaries  differ  from  the  ordinary  Albert  Smith 
variety  only  in  having  a  thick  bulb  instead  of  a  thin  bar.     They  ai'e  now 


Fig.    197.— Thomas'     Bulb    Eetroflexion 
Pessary. 


380  MINOR    GYNECOLOGICAL    MANIPULATIONS. 

kept  in  stock  in  sets  by  Pb.  H.  Scbmidt,  instrument-maker,  under  the  name 
of  tbe  Munde  retroflexion  pessary.  Tbey  are  shorter  and  wider  than  the 
Thomas  bulb  pessaries,  "which  I  find  too  long  for  the  majority  of  vaginse, 
although  excellent  as  supporters. 

A  useful  form  of  this  pessary,  in  certain  cases  of  heavy  (subinvoluted  or 
hj'perplastic)  uteri  with  a  steady  backward  tendency  of  the  fundus,  is  that 
in  shape  of  the  capital  letter  U ;  the  uterus  rides  in  this  pessary  as  in  a 
saddle,  the  cervix  being  on  a  level  with  the  lower  curve  ;  a  slight  down- 
ward bending  of  the  i3oint  of  the  anterior  arch  will  obviate  the  otherwise 
probable  pressure  on  the  urethra. 

All  these  pessaries  are  of  course  made  of  hard  rubber. 
By  making  the  posteiior  bulb  broader,  rather  square  at   each  end,  a 
greater  lateral  tension  of  the  posterior  pouch  may  be  obtained,  and  pro- 
lapsed ovaries  thus  lifted  up.     The  Albert  Smith  pessaries  are  also  made 

of  elastic  strings  of  brass  threads  covered  with 
hard  rubber  (Otto  &  Sons),  and  are  then 
springy  and  slightly  flexible.  They  are  very 
useful  in  cases  where  a  steady  unyielding  press- 
ure gives  too  much  pain,  and  may  be  em- 
ployed to  habituate  the  parts  to  a  pessary.  I 
foT^^iroa!xi^nTndko\apJdo7l  often  use  them  as  forerunners  to  a  hard  pes- 
"®*'  sary.      The   malleable  copper   rings    covered 

with  soft  rubber,  which  can  be  modelled  to  any  shape,  possess  merely 
the  advantage  of  malleability  ;  their  soft  covering  renders  them  unfit  for 
constant  use.  A  pessary  which  comes  under  this  category,  but  acts  on  the 
single-lever  principle,  is  that  of  Noeggerath.  The  posterior  bar  is  made 
either  slender  or  bulbous  ;  the  anterior  bar  always  has  a  urethi-al  depres- 
sion. It  has  answered  very  well  with  me  when  I  have  been  unable  to 
shape  a  Smith  to  a  capacious  flabby  vagina  with  gaping  orifice. 

Dr.  Studley,  of  New  York,  has  devised  a  Smith  pessary  with  a  ring 
attached  to  the  posteiior  arch,  into  which  the  cervix  is  to  fit  so  as  to  in- 
sure the  backward  fixation  of  the  latter,  while  the  lever  action  elevates  the 
fundus.  I  have  not  used  it,  but  cannot  help  wondering  whether  the  lever 
action  is  not  interfered  with  by  the  ring.  It  would  seem  to  me  a  useful 
instrument  in  certain  cases  of  retroversion  of  the  anteflexed  uterus,  where 
the  flexure  of  the  cervix  must  be  overcome  by  backward  traction  while  the 
fundus  is  elevated.  For  this  displacement  I  have  found  it  difficult  to  secure 
a  supporter. 

The  so-called  '•'  sleigh  "  pessary,  which  is  claimed  by  Chrobak,  of  Vi- 
enna, and  in  modified  form  by  Veuillot,  of  Paris,  and  Schultze,  of  Jena,  is, 
no  doubt,  an  excellent  instrument  for  those  cases  in  Avhich  the  cervix  shows 
a  tendency  to  slip  forward  instead  of  backward,  as  the  fundus  is  elevated. 
The  cervix  is  held  back  by  the  reflected  anterior  bar,  which  of  course 
must  not  be  so  near  the  posterior  bar  as  to  leave  no  room  for  the  cei'vix 
in  the  pessary.  The  modifications  mentioned  consist  merely  in  the  in- 
crease of  reflexion  of  the  anterior  bar. 

All  these  lever  pessaries  are  liable  to  press  more  or  less  severely  on  the 


PESSARIES    FOR    RETRO-DISPLACEMENTS. 


181 


rectum,  when  the  body  of  the  uterus  shows  a  tendency  to  backward  dis- 
placement while  the  pessary  is  in  the  vagina.  The  only  means  of  over- 
coming this  pressure  is  to  carefully  measure  the  vagina,  and  adapt  the 
curves  of  the  supporter  to  the  dimensions  and  curves  of  the  vagina. 
Special  rules  cannot  be  given. 

Introduction. — No  retroversion  pessary  should  be  introduced  until  the 
uterus  has  been  replaced.  The  introduction  may  take  place  in  the  dorsal 
position,  or  in  the  left  latero-abdom.- 
inal  decubitus.  Formerly,  the  dor- 
sal was  universally  employed,  the 
pessary  being  guided  sidewise  be- 
tween the  labia  by  either  hand,  the 
posterior  sharp  curve  ahead,  until 
the  cervix  was  reached,  when  the  in- 
dex-finger depressed  the  posterior 
arch  until  it  was  below  the  cervix, 
and  then  pushed  it  up  into  the  pos- 
terior pouch.  This  plan  had  two  great  disadvantages  :  1.  The  rule  to  re- 
place the  uterus  cannot  well  be  observed  in  the  dorsal  position,  because 
the  displaced  fundus  often  refuses  to  become  anteverted  by  vaginal  manip- 
ulation, and  if  replaced,  as  of  course  occasionally  occurs,  will  at  once  fall 
back  again  as  soon  as  the  finger  is  withdrawn.  The  sound,  it  is  true,  can 
be  and  has  been  used  to  replace  the  uterus,  the  pessary  being  slipped 
into  the  vagina  over  the  sound,  which  is  not  withdrawn  until  the  pes- 
sary is  in  place.  I  have  already  stated  that  the  reposition  of  the  uterus 
by  the  sound  is  admissible  only  when  the  fingers  fail  to  accomplish  it. 
2.  The  index-finger  often  finds  great  difficulty  in  pushing  back  the  poste- 
rior arch  behind  the  cervix,  partly  because  in  pessaries  with  sharp  posterior 
curve  it  is  no  easy  matter  to  press  the  arch  so  far  backward  and  down- 
ward, and  chiefly  because  the  parts  are  so  slippery  that  the  finger  slips 
fi'om  the  slender  posterior  bar. 


!Noeggerath's    Kstro version    Bulb-pes- 
sary. 


Fig. 


SCO. — Studley's  Ring-pessary  for  Retro- 
version of  the  Anieflexed  Uterus. 


Fig.  201. — "Sleigh"  Fcssary,  for 
Retroversion. 


I  have,  therefore,  for  a  number  of  years  introduced  all  lever  retrover- 
sion pessaries  in  the  latero-abdominal  position,  first  replacing  the  uterus  by 
the  fingers,  for  which  maneuvre  this  position  has  special  advantages.  In 
cases  of  extreme  difficulty  the  knee-breast  position  was  used.     And  I  have 


382 


MINOR    GYNECOLOGICAL    MANIPULATIONS. 


reversed  the  method  of  introducing  the  pessary,  inserting  it  with  the  con- 
cavity of  tlae  long  curve  downward,  that  is,  upside  down,  then  turning  and 
adjusting  it.  The  method  which  I  pursue,  and  which  I  have  not  seen  de- 
scribed elsewhere,  but  which  no  doubt  is  practised  by  many  gynecolo- 
gists to  whom  naturally  its  simplicity  and  efficiency  has  recommended  it, 
is  the  following : 

The  patient  being  in  Sims'  position,  the  uterus  is  replaced  by  two  fin- 
gers in  the  usual  way.  The  dimensions  of  the  vagina  are  then  taken  and 
a  properly  curved  pessary  of  correct  size  is  chosen.  This  is  dipped  in 
warm  water  and  then  in  vaseline  or  any  emollient,  and  grasped  between 
the  thumb  and  first  two  fingers  of  the  right  hand,  with  the  posterior  arch 


Pig.  209.— Introduction  of  a  Lever-pessary  (Albert  Smith's).    Patient  in  left  Latero-abdominal  Position. 

First  step  (P.  F.  M.). 

pointing  downward.  The  labia  are  well  separated  by  thumb  and  fore- 
finger of  the  left  hand,  the  operator  standing  slightly  behind  his  patient  so 
as  to  admit  the  light  (the  pessary  can,  however,  be  quite  as  well  introduced 
under  the  clothes)  and  the  curved  arch  of  the  pessary,  P  (see  Fig.  203), 
is  gently  inserted  between  the  labia  until  it  enters  the  vaginal  orifice 
proper.  The  resistance  of  the  perineum  (which  is  quite  strong  in  nulli- 
parae or  if  the  pessary  is  large)  is  easily  overcome  with  but  little  pain  by 
steadily  and  gently  pressing  back  the  pessary  as  soon  as  its  posterior  arch 
is  within  the  vagina  ;  or  the  index-finger  of  the  left  hand  may  do  this.  As 
the  perineum  is  retracted,  the  pessary  is  pressed  inward  until  its  posterior 
bar  rests  in  front  of  the  cervix  in  the  anterior  vaginal  pouch.  The  trans- 
verse diameter  of  the  pessary  corresponds  to  the  longitudinal  diameter  of 
the  vulvar  cleft.     This  is  the  first  step  (Fig.  202). 


PESSAEIES    FOE    EETRO-DISPLACEMENTS. 


383 


The  second  step  begins  by  gently  rotating  the  pessaiy,  so  that  its  right- 
hand  bar,  R  (Fig.  203),  stands  slightly  higher  than  the  left-hand  bar,  L  ;  the 
pessary  crosses  the  vulvar  cleft  diagonally.  This  is  done  in  order  to  place 
the  right  upper  curve  of  the  posterior  arch,  RP,  more  in  reach  of  the  finger. 
The  index-finger  is  now  introduced  above  the  pessary,  and  with  palmar  sur- 
face upward  passed  under  the  posterior  arch  P,  and  the  point  EP,  seized 
by  the  first  joint  of  the  finger.  It  is  important  that  the  finger  should 
be  assured  of  a  perfectly  firm  grasp  of  this  spot  of  the  pessary.  If  neces- 
sary, the  left  hand  may  seize  the  projecting  beak  of  the  pessary  A,  and 
rotate  the  instrument  to  suit  the  internal  finger.  The  first  joint  of  the 
right  index-finger  ha\ang  firm  grasp  of  the  pessary  at  RP,  and  the  oj)era- 
tor  standing  behind  the  patient's  sacrum,  with  his  left  arm  resting  on  her 
right  hip,  lifts  the  arch  P  up,  draws  it  slightly  toward  himself  and  the  pos- 
terior vaginal  wall,  and  by  one  rapid  twisting  motion,  from  the  metatarso- 
phalangeal articulation  and  the  wrist,  rotates  the  pessary  slightly  about 


Fig.  203. — Introduction  of  Lever-pessary  (Albert 
Smith's).  Second  step,  first  action.  The  arrows  show 
the  direction  of  rotation  of  either  end.  Letters  cor- 
respond to  diagonal  axis  of  vagina  (P.  F.  M.). 


Fig.  204.— Introdnction  of  Lever- 
pessary  (Albert  Smith's).  Second 
step,  second  action.  Letters  corre- 
spond to  longitudinal  axis  of  vagina 
(P.  F.  M.). 


its  longitudinal  axis  and  lifts  it  behind  the  cervix  (Figs.  203  and  204).  If 
the  cei-vix  is  long,  or  situated  low  in  the  pelvis,  the  pessary  will  spring 
into  the  posterior  pouch  almost  with  a  snap.  The  third  step  is  to  fix  the 
posterior  arch  P  firmly  behind  the  cervix,  by  placing  the  index-finger  on 
the  beak  A,  and  depressing  it  toward  the  perineum,  thereby  tilting  up  the 
posterior  arch  and  assuring  the  replacement  of  the  uterus  (Fig.  205). 

This  method  of  introducing  a  lever-pessary  is  eas}',  rapid,  and  entirely 
painless,  unless  too  large  an  instrument  be  used,  or  the  cervix  be  so  low 
as  to  be  touched  by  the  pessary  during  the  second  step  of  backward  ro- 
tation. The  difiiculties  which  I  have  seen  beginners  encounter  consisted 
in  pain  during  the  passage  through  the  vaginal  orifice,  and  failure  to  seize 
the  proper  portion  of  the  instrument  with  the  finger  in  the  second  step  (Fig. 
203,  RP).  The  pain  at  the  orifice  depended  entirely  upon  the  omission  to 
push  back  the  perineum,  and  the  consequent  pressure  by  the  right  bar  of  the 
pessary  on  the  sensitive  vestibule.  The  failure  to  grasp  the  right  curve, 
RP,  with  the  finger  was  due  to  non-comprehension  of  the  princixole  of  the 


384 


MIlSrOR    GYNECOLOGICAL    JMAlSTIPULATIOlSrS. 


metliod,  and  omission  to  rotate  the  pessary  with  the  left  hand  at  the  beak, 
so  as  to  have  EP  within  easy  reach.  The  usual  fault  was  that  the  pessary 
was  introduced  too  far,  and  the  arch  EP  could  not  be  easily  reached  by 
the  finger.  The  result  of  not  securing  a  firm  grasp  on  the  arch  at  EP,  was 
that  the  traction  was  always  exerted  nearer  the  other  curve  of  the  arch  LP 
(see  Fig.  203),  and  the  operator  was  astonished  to  find  that  he  had  placed 
the  pessaiy  behind  the  cervix,  with  the  arch  P  pointing  downward  toward 
the  rectum,  that  is  to  say,  upside  down.  Of  course,  a  pessary  so  placed 
could  but  give  pain  and  do  harm.  Occasionally,  if  the  parts  are  too  thor- 
oughly lubricated,  the  finger  may  slip  from  the  posterior  arch  and  the 
maneuvre  fail  for  the  moment,  even  in  experienced  hands. 


Fig.  205. — Introduction  of  Lever-pessary  (Albert  Smith's).    Third  step  (P.  F.  M.)- 

The  double  lever  pessaries,  like  Hodge's,  Smith's,  Thomas',  Sims',  are 
best  introduced  in  this  manner,  but  the  single  levers,  like  Noeggerath's, 
are  also  easily  applied  as  described. 

The  usual  method  consists  in  inserting  the  pessary  with  the  posterior 
arch  and  larger  concavity  pointing  upward,  passing  it  in  front  of  the  cer- 
vix, and  then,  with  the  index-finger  pressed  against  the  cross-bar  under  the 
pessary,  guiding  the  posterior  arch  behind  the  cervix.  The  disadvantage 
of  this  method  in  the  want  of  jourchase  of  the  finger  on  the  slender  bar  has 
already  been  referred  to. 

The  plan  here  described  at  length  has  the  advantage  of  giving  the  in- 
dex-finger a  hold  on  the  superior  crossbar  of  the  pessary,  which  inva- 
riably enables  the  operator  to  place  it  behind  the  cervix  if  he  has  chosen 
his  case  and  his  instrument  properly. 


PESSARIES    FOR    RETRO-DISPLACEMENTS.  885 

The  steps  briefly  repeated  are  :  1.  Seize  the  pes.3ary  with  two  fingers  of 
right  hand,  gently  insert  it  between  the  labia,  which  are  separated  by  the 
left  hand.  Press  back  the  perineum  and  insert  the  pessary  till  it  touches 
the  anterior  wall  of  the  cervix.  2.  Rotate  it  by  external  hand,  if  necessary, 
so  that  its  upper  end  is  conveniently  reached  by  the  right  index-finger  ; 
place  the  latter  under  the  right  upper  curve  of  the  posterior  arch,  firmly 
seize  it  and  lift  it  backward  and  upward  behind  the  cervix  by  a  twisting 
motion.     3.  Depress  anterior  beak  to  fix  posterior  bar  behind  the  cervix. 

As  a  rule,  the  left  hand  is  not  needed  to  manipulate  the  beak  of  the 
l^essary. 

If  the  pessary  is  large  or  sharply  cuiwed,  like  the  U  form  spoken  of, 
and  the  vaginal  orifice  comjDaratively  narrow,  it  is  advisable  to  retract  the 
perineum  to  its  utmost  by  the  Sims  speculum,  and  introduce  the  pessary 
through  the  speculum.  In  fact,  it  is  usually  good  practice  to  examine  the 
relations  and  appearance  of  a  retroversion  pessary  through  Sims'  speculum, 
and  ascertain  by  the  eye,  as  well  as  by  the  touch,  whether  it  interferes  with 
the  motion  of  the  uterus  and  vagina  during  respiration  or  not. 

This  minute  description  of  how  to  inti'oduce  and  fit  a  lever-jDessary  is 
by  no  means  unnecessary.  The  limits  of  the  majority  of  text-books  pre- 
vent these  details  from  receiving  sufficient  consideration,  and  the  young 
practitioner  find  himself  totally  at  a  loss  for  information  as  to  which  end 
of  a  pessary  is  to  be  inserted  first,  and  which  curve  j)oiiits  up  or  down. 
The  result  is  that  lever-pessaries  are  often  inserted  with  the  sharp  curve 
in  front  of  the  cervix,  or  pressing  downward  upon  the  rectum.  I  have 
repeatedly  removed  pessaries  which  had  been  introduced  in  this  manner 
by  other  practitioners.  Li  no  one  manipulation  did  I  find  the  gentlemen 
who  for  years  joined  my  private  classes  in  practical  gynecology  (nearly  all 
of  them  older  practitioners)  so  deficient,  and  therefore  so  anxious  to  learn, 
as  in  this  matter  of  selecting,  introducing,  and  adapting  pessaries. 

I  am  convinced  that  the  time  spent  in  carefully  perusing  this  chapter 
will  not  be  wasted,  and  trust  that  it  will  enable  practitioners  who  have 
exj)erienced  the  usual  difficulties  to  overcome  them  with  but  little  trouble. 

After  introducing  a  pessary,  retro-  or  anteversion — in  fact,  any  pessary 
— the  patient  should  be  examined  in  the  erect  position  in  order  to  deter- 
mine whether  the  instrument  is  too  large  or  too  small,  whether  it  jDrojects 
from  the  vagina — in  short,  whether  it  fulfils  its  purpose  of  su^oporting  the 
uterus  during  the  position  when  such  support  is  most  needed. 

The  removal  of  these  retroversion  pessaries  is  easily  accomplished  by 
physician  or  patient,  by  simply  hooking  the  index-finger  into  the  anterior 
beak  or  bar,  making  gentle,  steady,  downward  traction,  and  as  the  instru- 
ment is  felt  to  yield,  turning  it  side  upward,  and  withdraAving  it  in  this 
position  from  the  vagina.  By  placing  one  foot  on  a  chair,  or  crouching, 
the  removal  by  the  patient  herself  is  facilitated. 

A  retroversion  pessary  on  essentially  a  lever  principle  is  that  of  Fowler 
(Figs.  206  and  207) ;  the  perforated  tongue  goes  in  front,  the  bevelled  bor- 
der behind  the  cervix,  and  the  fundus  is  tilted  up  by  the  downward  press- 
ure of  the  anterior  tongue  in  the  erect  position.  I  have  seldom  used  it, 
25 


386  MINOR    GYNECOLOGICAL    MANIPULATIONS. 

but  it  is  highly  recommended  by  its  inventor  and  by  Dr.  Sims,  and  I  can 
readily  imagine  how  in  retroversion  with  descensus  it  might  prove  useful. 
From  its  construction  I  should  have  supposed  it  to  be  designed  for  ante- 
version,  the  long  tongue  suppoi'ting  the  uterus.  Dr.  Thomas,  in  his  latest 
edition  (Novembei*,  1880),  calls  it  "Fowler's  pessary  for  anterior  disj^lace- 
ments  ; "  the  directions  of  the  inventor,  however,  are  for  retroversion. 

A  retroversion  pessary,  constructed  for  another  object,  is  the  galvanic 
lever-pessary  of  Hanks  for  amenorrhea,  the  posterior  portion  of  which  is 
composed  of  alternate  copper  and  zinc  beads  strung  on  copper  wire,  which 


Fig.  206.— Fowler's  Eetroversion  Fig.  207. — Fowler's  Retroversion  Pessary  with 

Pessary.  Anterior  Movable  Bow. 

in  the  anterior  part  is  covered  with  soft  rubber.  The  galvanic  current 
generated  by  the  action  of  the  acid  vaginal  secretion  on  the  alternate  cop- 
per and  zinc  beads,  might  possibly  stimulate  the  uterus  to  growth  and 
metrostaxis ;  but  I  doubt  whether  the  soft  parts  would  long  endure  the 
pressure  of  the  beads  at  the  posterior  segment. 

Abrasions  and  indentations  made  by  lever  pessaries  are  usually  found 
behind  the  cervix  and  along  either  descending  branch  of  the  pubic  arch. 
In  the  latter  spot  the  injuiy  is  generally  a  longitudinal  sulcus  cut  by  the 
slender  side-bar  of  the  pessary, 

c.  Lateral  Displacements. 

Lateral  displacements  are  but  little  benefited  by  vaginal  pessaries. 
Some  ingenious  gynecologists  have  endeavored  to  lift  up  the  latero-verted 
or  -flexed  fundus  by  elevating  the  corresponding  side  of  an  anteversion  cup 
pessary,  or  the  bar  of  a  retroversion  pessary,  but  their  efforts  have  not  been 
very  successful.  The  only  supporter  which  really  draws  the  displaced  cer- 
vix back  and  pushes  the  latero-verted  fundus  up  toward  the  median  line  is 
one  which  gains  its  pui'chase  in  the  uterine  cavity.  It  acts  by  straighten- 
ing the  uterus,  the  lower  flange  on  which  the  cervix  rests  being  of  unequal 
width,  the  wider  on  the  side  toward  which  the  cervix  points.  The  object 
is  thereby  to  push  the  cervix  toward  the  median  line.  The  origin  of  these 
lateral  displacements,  either  in  congenital  shortening  or  cicatricial  contrac- 
tion (after  cellulitis)  of  the  broad  ligament  of  the  affected  side,  usually  pre- 
vents any  efforts  for  the  relief  of  this  condition  from  being  successful. 

d.  Prolapsus  of  the  Ovaries. 

For  prolapsus  of  the  ovaries  certain  modifications  of  lever-pessaries 
have  been  devised,  all  designed  to  prevent  the  recurrence  of  the  prolapse 
by  stretching  the  posterior  vaginal  pouch  in  the  antero-j)osterior  direction 


PESSARIES  FOR  CYSTOCELE,  RECTOCELE,  AIS^D  PROLAPSUS.      387 

or  laterally,  and  by  relieving  pressure  on  a  prolapsed  and  adherent  ovary. 
The  former  indication  is  more  or  less  filled  by  Thomas'  bulb-pessary  with 
diflerent-sized  bulbs,  broader,  thicker  ;  the  latter,  by  Gehruug's  retrover- 
sion pessary  with  central  depression,  or  one  of  Thomas'  bulb-pessaries 
similarly  or  unilaterally  bevelled  out.  The  usual  variety  of  ovarian  j)ro- 
lapse  is  behind  the  uterus  in  Douglas'  pouch,  or  one  of  the  retro-lateral 
pouches.  The  retention  of  a  prolapsed  ovary  by  a  pessary  is  by  no  means 
so  easy  as  that  of  the  fundus  uteri.  The  extreme  mobility  of  the  ovary 
renders  it  very  liable  to  slip  down  behind  the  pessary,  when  the  j)ain  of  its 
compression  will  soon  herald  the  accident  and  require  the  removal  or 
change  of  the  pessary. 

The  utility  of  glycero-carbolized  pledgets  of  cotton  in  retroversion  and 
prolapsed  ovaries,  as  a  means  of  support  when  hard  pessaries  are  not 
borne,  has  been  sufficient^  pointed  out  under  Tampons,  as  also  the  benefit 
to  be  derived  from  a  firmly  packed  column  of  cotton  in  displacements  with 
parametran  infiltrations  and  hyperemic  conditions  of  the  uterus  and  ad- 
nexa. 

By  packing  the  anterior  vaginal  pouch  thoroughly  full  of  glycero-car- 
bolated  cotton  pledgets,  the  cervix  may  be  crowded  against  the  posterior 
vaginal  wall  and  the  uterus  retained  in  anteversion.  If  the  fundus  shows 
a  tendency  to  retrovert  in  spite  of  this,  the  posterior  cul-de-sac  may  also 
be  filled  with  cotton,  and  the  whole  may  be  suj^ported  by  a  column. 
These  tampons  should  be  changed  every  day,  or  other  day,  until  a  -per- 
manent  supporter  can  be  worn. 

e.  Pessaries  for  Cxjstocele,  Rectocele,  and  Prolapsus  Uteri. 

The  best  cj'stocele  pessary',  in  my  opinion,  is  Gehrung's  anteversion 
pessary  (Fig.  182).  Indeed,  all  anteversion  pessaries  are,  to  a  certain  de- 
gree, useful  in  cystocele.  An  elastic  ring,  Fig.  208,  will  also  answer  -when 
no  hope  of  cure  of  the  cystocele  is  entertained.  The  Gehrung  pessarv, 
with  daily  tannin  pledgets  between  the  branches,  offers  the  best  hoj)e  of 
cure.  Rectocele  is  relieved  by  a  large  Hodge,  or  Smith,  or  a  ring  pessary. 
A  cure  is  generally  effected  only  by  a  plastic  operation. 

Vaginal  pessaries  for  the  relief  of  j^rolapsus  uteri  et  vaginae  consist 
mainly  in  such  contrivances  as  act  by  their  size,  and  by  distending  the 
vaginal  walls  to  their  utmost.  These  instruments  then  rest  on  the  floor  of 
the  pelvis,  and  are  prevented  from  being  forced  out  by  whatever  contrac- 
tility exists  in  the  perineum  and  vaginal  orifice.  As  regards  curative 
properties,  they  are  all  worthless,  except  one,  the  largest  size  of  Gehrung's 
anteversion  pessary.  In  construction  many  are  faulty  and  dangerous, 
unless  very  carefully  watched.  Of  these  latter,  the  old  time-honored 
Zwanck,  with  wide-spread  wings,  is  the  best  example  ;  it  is  not  ^-et  obso- 
lete, unfortunately.  I  have  seen  one  case  of  vesico-vaginal  fistula  produced 
by  the  pressure  of  one  of  these  wings.  It  keeps  up  the  uterus,  true,  but 
at  the  expense  of  all  hope  of  ultimate  cure,  and  with  danger  to  the  patient, 
unless  she  be  intelligent  enough  to  remove  it  daily,  and  keep  her  vagina 
well  cleansed.     That  of  Noeggerath  is  built  on  the  same  principle,  and 


388  MINOR    GYNECOLOGICAL    MANIPULATIONS. 

open  to  the  same  objections.     They  are  introduced,  closed,  and  expanded 
by  a  screw  mechanism  in  the  handle  when  in  the  vagina. 

The  large,  thick  ring-pessaries  of  Martin,  Braun,  and  others,  are  made 
of  glass,  hard  rubber,  wood,  varnished  canvas,  etc.,  and  are  a  necessary 
evil  in  some  aggravated  cases  of  prolapsus  in  old,  withered  patients.  They 
keep  up  the  uterus,  if  retained  (wherein  they  may  be  aided  by  a  T-band- 

age),  and  that  is  all.  In  many  cases,  how- 
ever, that  is  all  that  is  expected  or  possible. 
So  far  as  possibility  of  injury  is  concerned, 
the  inflated  soft-rubber  bags  of  Gariel  and 
Braun  are  certainly  the  best ;  they  are  in- 
troduced closed,  and  expanded  with  air  or 
water,  and  can  easily  be  emptied  and  re- 
filled by  the  patient  herself.  They  require 
daily  removal  and  cleansing,  being  best 
kept  overnight  in  a  basin  of  carbolized 
water.  Large  glass  balls  have  been  used 
for  the  same  pui-pose.     All  these  instru- 

PlG.  208.— Peaslee's  Elastic  King-pessary.       mcnts,  it   will   be    SCCn,   still    belODg    tO    the 

primeval  age  of  the  science  of  mechanical 
support  in  uterine  displacements.  They  are  stiU  largely  employed  for 
want  of  something  better. 

Gehrung's  largest  sized  anteversion  pessary  has  repeatedly,  in  my 
hands,  perfectly  retained  a  complete  prolapse  of  uterus  and  vagina.  Be- 
fore I  succeeded  in  having  the  proper  Gelirung's  pessary  made  out  of 
Hodge's  j)essaries,  I  used  the  Albert  Smith,  simply  approximating  the 
posterior  bar  and  the  anterior  beak,  until  the  former  stood  exactly  above 
the  beginning  of  the  smaller  curve  where  it  bends  down  toward  the  an- 
terior beak  ;  the  distance  between  these  two  points  was  two  inches.  With 
this  largest  sized  pessary  I  have  retained  one  of  the  worst  prolapses  I  ever 
saw,  in  a  woman  sixty  years  of  age.  She  wore  the  pessary  for  months  with 
perfect  comfort,  and  for  aught  I  know,  is  wearing  it  still.  It  kept  up  the 
anterior  wall  of  the  vagina  so  perfectly,  that  the  uteras  could  not  descend. 
By  separating  the  bars  at  the  posterior  curve  more  than  usual,  the  reten- 
tive power  is  increased.  Any  large  Albert  Smith  or  Hodge  pessary  may 
thus  be  converted  into  an  excellent  supporter  for  prolapsus  uteri  at  a  mo- 
ment's notice. 

It  is  scarcely  necessary  to  say  that  every  prolapsed  uterus  should  be 
replaced  before  introducing  the  supporter.  The  dorsal  position  answers 
for  the  application  of  all  these  instruments. 

More  than  usual  care  should  be  exercised  in  guarding  against  excoria- 
tion and  ulceration  while  these  supjjorters  are  worn  ;  the  great  pressure 
of  the  uterus,  which  constantly  endeavors  to  force  its  way  down,  would 
naturally  lead  to  some  such  injury.  Occasionally,  a  prolapsus  is  uninten- 
tionally cured  by  the  cicatricial  contraction  of  the  vagina  following  an  ul- 
ceration produced  by  the  too  long  retention  of  one  of  these  large  pessaries. 
I  recently  saw  such  a  case,  as  the  result  of  five  years'  retention  of  a  glass 


VAGIN0-ABD0MI1S"AL    SUPPORTERS. 


389 


ring.  As  the  extent  of  such  vilceration  cannot,  however,  be  limited  at 
will,  it  is  hardly  fair  to  the  patients  to  allow  them  to  run  the  risk,  even 
with  a  possible  chance  of  cure. 

3.    VAGrNO-ABDOMTNAL    SuPPOETEES. 

Supporters  which  are  furnished  with  attachments  to  bands  encu'cling 
the  body  are  used  either  for  retro-displacements  in  which  a  lever-pessary 
fails  to  retain  or  hft  the  fundus,  or  for  prolapsus  of  the  vagina  and  uterus, 
which  overcome  all  the  intravaginal  instruments  mentioned. 

The  cases  of  relro-disjjlacement  requiring  an  external  support  for  the 
internal  pessary,  are  those  of  short  retro-cervical  pouch,  with  heavy,  en- 
larged, perhaps  adherent  uterus.  In  these  it  frec[uently  happens  that  no 
mere  vaginal  instrument  is  retained  or  answers  the  purpose  ;  the  stronger 


Pig.  209. — Cutter- 'i'hcimas  Vaginal  Stem- 
pcssary  for  Retroversion. 


Fig.  210. — Thomas'  Chair-pessary  with"' 
Stem,  for  Retroversion  and  L'rolapsns. 


upward  pressure  of  a  pessary  held  in  place  by  an  abdominal  belt  and  sacral 
strap  is  required  to  deepen  the  posterior  pouch,  stretch  the  adhesions  and 
elevate  the  fundus.  Pessaries  of  this  kind  are  those  of  Cutter  modified  by 
Thomas  (Figs.  209  and  210).  The  rubber  tubing  by  which  these  pes- 
saries are  attached  to  the  abdominal  belt  is  designed  to  exert  an  elastic 
upward  pressure.  The  peculiar  curve  of  the  pessary  adapts  it  to  the  pos- 
terior vaginal  wall.  Occasionally  these  pessaries  may  be  used  to  elongate 
the  anterior  vaginal  pouch.  In  many  cases  in  my  hands  these  supporters 
also  failed  to  push  up  the  fundus  ;  and,  if  the  uterus  was  really  adherent 
or  very  heavy,  the  supporter  usually  slipped  down,  so  as  to  emerge  from 
the  vagina,  or  prove  inert.  The  addition  of  an  anterior  curve  and  tube 
passing  up  over  the  pubes  might  make  the  instrument  more  serviceable 
Still,  in  several  most  intractable  cases  of  retroflexion,  in  virgins  and  mar- 
ried nullij)ar8e  and  multiparte,  in  whom  lever-pessary  after  lever-pessary, 
of  different  sizes,  shapes,  and  ciu'ves,  with  and  without  posterior  bulb, 
failed  to  retain  the  fundus  in  the  anteverted  position  to  which  it  could 
easily  be  replaced,  as  a  last  resort  I  tried  a  Cutter  pessary  with  thick  pos- 
terior bulb,  and  the  regult  was  eminently  successful.  The  patients  de- 
clared themselves  satisfied  to  endure  the  inconvenience  of  the  tubes  and 


S90 


MIlSrOR    GYNECOLOGICAL^  MANIPULATIO])«"S. 


straj)s  for  tlie  sake  of  the  perfect  reposition  of  the  uterus  which  the  ap- 
paratus afforded  them.  They  were  taught  to  remove  the  pessaiy  at  night 
and  to  reintroduce  it  in  the  morning  before  rising,  even  learning  to  do  both 
in  the  knee-breast  position,  thus  giving  the  uterus  no  opportunity  to  ret- 
rovert  before  the  pessary  was  replaced.  In  one  case,  however,  with  heavy 
uterus,  shghtly  sinistro-retroverted  and  somewhat  bound  down  by  con- 
traction of  the  left  broad  ligament,  after  all  the  retroversion  pessaries  had 
failed,  the  Cutter  also  shjjped  down  and  proved  useless. 

As  soon  as  the  vagina  is  fitted  for  it,  an  intravaginal  supporter  should 
be  appHed. 

The  number  of  supporters  for  prolapsus  uteri  is  legion,  many  of  them 
being  patented  and  soiu-ces  of  income  to  their  owners,  if  not  of  benefit  to 
the  women  who  buy  and  wear  them.      The  principle  upon  which  they 


G.TICMANNfi-Cn.N.Y. 


Pig.  211. — Thomas'  Cnp  and  Stem  Supporter 
for  Prolapsus    (modified  from  Cutter). 


Fig.    212. — Tiemann's  Supporter  for  Prolapsus. 


all  act  is  apparent  on  a  glance  at  Figs.  211  and  212;  and  so  also  are 
their  defects.  A  small  cup,  ring,  or  ohve  is  designed  to  fit  directly  over 
the  cervix  and  hold  up  uterus  and  vagina.  The  former  often  succeeds,  but 
the  latter  as  often  fails  because  the  flabby,  redundant  vaginal  walls  force 
theu'  way  down  beside  the  central  supporter,  and  are  biaiised  and  excori- 
ated between  it  and  the  pelvic  wall.  It  may  be  assumed  as  a  fact  that  all 
such  supporters  which  actually  retain  a  prolapsed  uterus  and  vagina  of  the 
thu'd  degree,  do  so  by  exerting  a  pressure  on  whatever  point  they  happen 
to  touch,  which  is  sure,  sooner  or  later,  to  produce  an  ulceration,  the  dis- 
covery of  which  demands  the  removal  of  the  supporter  until  the  injury  is 
healed.  Besides,  the  immovable  stems  which  it  is  unavoidable  to  give 
these  instruments  in  order  that  they  may  possess  sufficient  resisting  power 
to  retain  the  uterus,  generally  are  the  cause  of  considerable  pain  to  the 
patient,  each  movement  forcing  the  tender  uterus  down  on  the  immovable 
support.  To  obviate  this,  the  stems  were  made  of  elastic  steel  springs,  or 
of  rubber  tubing  ;  or  a  spiral  wire  spring  was  inserted  into  the  stem.  But 
the  elasticity  of  the  stem  was  either  too  gTeat  (and  then  the  uterus  came 
down)  or  too  little  (and  the  pain  was  the  same) ;  or  the  constant  oscillation 
of  the  spiral  spring  produced  nervous  symptoms  similar  to  those  following 
masturbation,  as  I  saw  in  one  case. 


DANGERS    OF    A^AGIISTAL    PESSARIES.  391 

A  case  illustrating  the  dangers  attending  the  use  of  these  supporters  is 
reijorted  by  Dr.  J.  Steele  Bailey,  of  Stanford,  Ky.,  in  the  American  Prac- 
titioner for  June,  1882.  A  Tiemann  supporter  (Fig.  212)  was  applied  in  a 
case  of  complete  prolapsus  uteri  et  vaginse  and  did  perfectly  well  for  a 
week  ;  then,  while  churning,  an  accidental  strain  forced  the  uterus  through 
the  cup  of  the  supporter,  where  it  was  tightly  strangulated.  Only  after 
repeated  strenuous  efforts  at  reduction  was  it  possible  to  release  the  utems 
by  sawing  through  the  hard-rubber  cup.  The  uterus  protruded  to  the 
length  of  seven  inches  below  the  cup  and,  after  nearly  forty-eight  hours' 
imprisonment,  was  almost  gangrenous.     The  woman  eventually  recovered. 

Besides,  the  expense  of  these  contrivances  (in  this  country,  at  least) 
renders  them  beyond  the  means  of  the  very  women  who  need  such  sup- 
porters most,  the  hard-working  women  of  the  laboring  classes.  A  poor 
woman  who  has  to  do  washing  and  ironing,  or  scrubbing,  or  carry  a  pail 
of  water  \x^  three  or  four  flights  of  stairs,  and  who  is  not  able  to  rest  her- 
self after  confinement,  soon  acquires  a  prolapsed  ixterus,  and  cannot  afford 
to  spend  five  or  six  dollars  for  a  complicated  supporter,  which  is  easily 
spoiled  and  which,  after  a  few  days,  may  prove  useless.  The  ideal  pessary 
for  complete  prolapsus  uteri  is  yet  undiscovered.  I  really  do  not  know  of 
a  cheaper,  more  efficient  and,  for  its  possible  curative  properties,  more  de- 
sirable supporter  for  these  cases  than  the  large  tampon  of  cotton  soaked  in 
glycerole  of  alum  or  tannin  and  introduced  every  day  by  the  woman  herself 
and  retained  by  a  T-bandage.  I  have  already  described  this  supporter 
under  Tamponade  of  the  Vagina. 

Dangers. 

The  dangers  from  vaginal  pessaries  may  be  gathered  in  part  from  the 
remarks  attached  to  each  variety.  Complicated  and  hinged  pessaries  are 
far  more  likely  to  cut  into  the  vaginal  wall,  produce  offensive  discharge 
and  excoriation  than  simple  hard-rubber  rings.  The  same  is  true  of  soft 
pessaries  as  regards  the  discharge.  The  longer  a  pessarj'  is  left  in  the 
vagina  uncleansed,  the  more  it  will  be  incrusted  with  calcareous  deposits, 
and  the  more  irritating  will  it  become.  Cases  have  been  observed  in  which 
a  Zwanck  pessary  pei'forated  the  bladder,  and  instances  of  injury  of  the 
rectum,  and  of  Douglas'  pouch  have  been  rej)orted.  These  accidents  were 
mostly  produced  by  the  clumsy  old  pessaries,  which  were  wanting  in  all 
mechanical  principle  and  acted  only  by  their  bulk.  But  cases  of  ulcera- 
tion of  the  vaginal  wall  from  Thomas'  cup,  Hodge's  and  Smith's  lever  pes- 
sary, are  occasionally  met  with.  I  have  seen  one  instance  of  a  localized 
cellulitis  near  the  left  descending  ramus  of  the  pubic  arch  from  a  too  large 
Hodge,  and  one  case  in  which  one  of  the  hinges  of  a  well-fitting  Thomas 
cup-pessary,  which  had  been  left  in  the  vagina  for  five  months,  contrary 
to  particular  directions,  had  j^erforated  the  recto-vaginal  wall.  The  mi- 
nute fistula  only  admitted  a  fine  anatomical  probe,  and  healed  without  treat- 
ment in  a  week  after  removal  of  the  pessary.  With  due  attention  to  a 
proper  choice  of  pessary,  to  cleanliness  and  with  occasional  supervision, 
such  accidents  should  not  and  will  but  rarely  occur.     I  have  met  with  sev- 


392        MINOR  GYNECOLOGICAL  MANIPULATIONS. 

eral  cases  in  which  a  retroversion  lever-pessary,  which  apparently  wias  a 
perfect  fit  and  gave  no  inconvenience  whatever  for  a  number  of  weeks, 
suddenly  caused  pain,  and  on  examination,  was  found  to  have  completely 
turned  in  the  vagina,  so  that  the  retro-uterine  curve  pressed  into  the  rec- 
tum, and  in  one  case  the  pessary  had  shifted  completely  around,  the  pos- 
terior end  being  under  the  symphysis.  I  strongly  suspect  that  coition  had 
something  to  do  with  these  vagaries,  although  I  can  readily  imagine  how 
constipation  and  a  solid  fecal  evacuation  might  thus  displace  a  pessary. 
Worse  results  than  here  cited  are  not  reported  to  have  followed,  except 
one  case  of  myelitis  supposed  to  have  followed  a  pessary,  cited  by  Ver- 
neuil ;  and  Hegar  and  Chrobak  each  noticed  cancerous  infiltration  at  a 
spot  where  the  pressure  of  a  pessary  had  j)roduced  granulations.  Such 
cases  are  certainly  rare  exceptions,  and  cannot  weigh  as  counter-indications 
to  the  use  of  pessaries. 

Curability  of  Uterine  Duplacements. 

The  CURATIVE  results  from  pessaries  are  not  as  encouraging  as  we  could 
wish  them  to  be.  If  applied  at  an  early  stage  of  the  displacement,  and  es- 
pecially at  a  time  when  the  natural  involution  of  the  pelvic  organs — uterus, 
ligaments,  and  cellular  tissue — favors  a  restitutio  ad  integrum,  pessaries 
may,  after  a  certain  time,  several  months  or  more,  produce  an  entire  cure 
of  the  displacement.  This  is  particularly  true  of  retroversions,  prolapsus, 
rectocele,  and  cystocele.  Later  on  it  is  the  exception  to  find  the  relaxed 
ligaments  restored  to  their  normal  tone  and  tension.  Stiil,  I  have  seen 
within  a  year  an  old  retroversion  changed  almost  to  an  anteversion  by  a 
five  months'  use  of  an  Albert  Smith  pessary  ;  and  another  retroverted  uterus 
replaced  permanently  (at  least  up  to  the  present  time,  four  months)  by 
only  a  two  months'  use  of  the  same  instrument,  and  we  should  not  despair 
of  a  perfect  recovery  if  we  do  not  neglect  other  local  means  (astringents, 
hot  or  cold  injections)  and  general  tonics  to  strengthen  the  system. 

While  the  puerperal  state  is  a  particularly  favorable  time  to  act  upon 
the  displaced  uterus  (and  I  have  introduced  a  retroversion  pessary  as  early 
as  the  eighth  daj^  after  delivery),  we  must  not  expect  too  great  results 
even  then.  An  inveterate  retroversion  or  retroflexion  may  be  benefited  for 
a  while  until  the  patient  rises  and  walks  about,  when  usually  the  flabby 
uterus  flexes  over  the  posterior  bar  of  the  pessary  and  this  opportunity  for 
cure  is  lost.  Only  rest  in  bed,  until  subinvolution  has  been  entirely  com- 
pleted, two  to  three  months,  or  longer,  may  achieve  a  cure. 

With  this  doubtful  prospect  as  to  an  entire  cure  in  the  aggravated 
cases  of  each  displacement,  we  are  still  obliged  to  resort  to  pessaries  as  the 
best  palliative  measures  at  hand.  By  perseverance  and  ingenuity,  entire 
recovery  will  occasionally  be  accomplished  even  in  these  bad  cases.  The 
minor  degrees  are  readily  susceptible  of  cure. 

Thomas  states  that  in  the  treatment  of  no  form  of  uterine  disease 
has  he  experienced  so  much  satisfaction  and  accomplished  so  much  good 
for  his  patients,  as  in  anterior  displacements.  He  does  not  claim  to  have 
cured  the  displacement  or  distortion,  however  (at  least  he  speaks  only  of 


CURABILITY    OF    UTERINE    DISPLACEMENTS.  393 

"giving  relief,"  being  "rewarded  by  success,"  etc.  ;  nowhere  of  cure  in  that 
chapter  of  his  new  edition) ;  and  I  cannot  help  thinking  that  a  large  por- 
tion of  the  relief  experienced  by  the  patients  referred  to  by  him  was  due 
to  the  very  means  asserted  by  Emmet,  the  elevation  of  the  whole  uterus. 
This,  Thomas  denies ;  but  I  certainly  have  seen  no  sharp  flexion  of 
long  standing  become  straight  through  the  use  of  one  of  his  anteflexion 
pessaries,  or  those  of  any  one  else,  although  great  relief  is  undoubtedly 
aflbrded  which  may  even  continue  after  the  i:)essary  has  been  removed. 
According  to  this  author,  greater  skill  is  requii*ed  to  select  and  adjust  pes- 
saries for  anterior  displacements,  and  they  are  more  readily  productive  of 
danger  than  retroversion  pessaries.  My  experience  has  led  me  to  a  differ- 
ent conclusion,  which  I  know  to  be  shared  by  many  prominent  gj'necolo- 
gists.  The  danger  of  ulceration  from  the  pressure  of  one  of  the  compli- 
cated hinge  instruments,  above  described,  I  admit,  of  course  ;  but  I  have 
failed  to  observe  any  very  great  difficulty  in  selecting  or  choosing  a  proper 
pessary  for  an  anteversion  or  anteflexion  (at  least,  so  far  as  I  could  judge), 
or  in  fitting  it  to  the  vagina.  The  same  rules  as  to  size  and  adaptation  to 
the  vaginal  walls  apply  here  (only,  I  think,  in  a  less  degree)  as  with  ret- 
roversion pessaries.  And  as  regards  frequency  of  indication,  I  have  found 
at  least  ten  retroversion  pessaries  called  for  by  the  symptoms,  to  one  for 
anterior  displacement.  Perhajos  this  is  the  reason  why  I  have  met  with  so 
little  difficulty  in  choosing  the  latter.  To  projperly  fit  a  lever-j^essary  in  a 
case  of  acute  retrofiexion  with  sliort  posterior  vaginal  pouch,  or  of  heavy  ret- 
roverted  litems  of  the  third  degree  ivith  thickened  and  contracted  utero-rectal 
ligaments,  or  of  rectocele  and  lacerated  perineum,  has  ahvays  seemed  to  me  the 
severest  test  of  the  ingenuity  and  mechanical  skill  of  a  gynecologist  in  this 
department.  In  making  this  assertion,  I  do  not,  of  course,  refer  to  ante- 
flexion, which  I  have  already  stated  to  be,  in  my  opinion,  beyond  remedy 
by  a  vaginal  pessary. 

The  results  obtained  in  patients  who  are  able  to  give  themselves  the 
best  possible  care  are,  of  course,  much  better  than  can  be  exi^ected  in  the 
poorer  classes.  Such  success  as  reported  by  Dr.  F.  B.  Watkins,  of  Eich- 
mond,  Va.  {Virginia  Medical  Monthly,  November,  1875),  has  certainly  not 
been  my  experience  in  a  larger  number  of  cases  than  those  reported  by 
him,  and  treated  on  the  same  principles.  In  215  cases  of  uterine  displace- 
ment (retroversion  139,  anteversion  49,  prolapsus  27)  in  which  he  em- 
ployed mechanical  supports,  he  achieved 'the  following  results — Retrover- 
sion :  Complete  recovery,  114  ;  partially  reheved,  9  ;  slight  or  no  improve- 
ment, 12.  Anteversion  :  Kecovery,  34  ;  partially  relieved,  9  ;  slight  or  no 
improvement,  7.  Prolapsus :  Recover^'-,  22  ;  partially  relieved,  4  ;  slight 
or  no  improvement,  2.  Total  :  Recovery,  170  ;  partial  relief,  36  ;  slight  or 
no  relief,  21.  The  vaginal  supporters  used  were  all  constructed  on  the 
Hodge  closed  lever  principle,  of  block-tin  wire  and  hard  rubber,  accurately 
fitted.     No  vagino- abdominal  supporters  with  fixed  ends  were  used. 

Similar  successes  are  published  by  Dr.  P.  O'Connell,  of  Sioux  City, 
la.,  in  the  February,  1881,  number  of  the  Chicago  Medical  Journal  and 
Examiner.     He  reports  eight  cases  of  complete  cure,  all  of  retroflexion,  the 


394  MINOE    GYNECOLOGICAL    MANIPULATIONS. 

pessary  used  being  the  Albert  Smith  lever.  His  observation  of  the  patients 
extended  over  one  year,  the  shortest,  to  four  years,  the  longest  period  after 
the  removal  of  the  pessary,  and  in  no  case  did  the  displacement  return. 

My  experience  during  the  past  few  years  {collated  for  a  paper  on  the 
Curability  of  Uterine  Displacements,  which  I  read  before  the  International 
Medical  Congress  in  London,  in  August,  1881),  gives  me  the  following- 
figures  :  Out  of  2,500  patients  with  uterine  diseases,  I  find  895  instances 
of  displacement  or  distortion  of  the  uterus  of  one  variety  or  the  other. 
Of  these,  827  patients  were  married  and  68  single ;  624  had  had  one  or 
more  children.  Of  the  single  women,  only  5  had  a  simj)le  retroversion, 
and  3  a  retroversion  of  the  anteflexed  uterus.  All  the  other  single 
women  had  anteflexion  and  anteversion,  with  a  few  instances  of  latero- 
version  and  latero-flexion.  Among  the  married  nullipara),  only  15  had 
retro-displacements.  The  most  common  displacement  was  retroversion, 
of  which  there  were  348  cases,  as  compared  with  55  of  retroflexion.  There 
were  295  cases  of  anteflexion,  102  of  anteversion,  10  of  latero-flexion,  10  of 
latero-version,  5  ante-latero-flexion,  3  retro-latero-flexion,  1  anteversion  with 
latero  flexion,  23  anteflexion  with  retroversion,  21  descensus  with  retro- 
version, 13  total  pi'olapsus  uteri  et  vaginse.  In  8  cases  the  retroverted 
uterus  was  firmly  bound  down  by  adhesions.  In  this  classification  many 
cases  were  found  in  which  both  flexion  and  version  existed  ;  the  predomi- 
nating condition  was  chosen  to  designate  the  case. 

Of  these  895  cases  of  displacement,  184  were  treated  by  vaginal  and 
uterine  pessaries.  Thus,  of  the  403  cases  of  posterior  displacement,  96 
retroversions  and  31  retroflexions  were  treated  by  vaginal  pessaries,  the 
retroversions  chiefly  by  the  Albert  Smith  modification  of  the  Hodge  lever, 
occasionally  by  the  original  Hodge  or  Noeggerath's  cradle- j)essary ;  the 
retroflexions  by  my  modification  of  Thomas'  bulb  retroflexion  pessary.  A 
few  cases  in  which  no  lever-joessary  could  be  made  to  fit  were  relieved  by  a 
Peaslee  flexible  ring,  which  simply  lifted  up  the  whole  uterus,  and  by  a 
Cutter's  stem  with  bulb,  which  succeeded  in  retaining  the  organ  after  all 
other  pessaries  had  failed.  Only  in  three  cases  was  it  necessary  to  prevent 
the  constant  retroflexion  of  the  uterus  over  the  posterior  bar  of  a  lever- 
pessary  by  inserting  a  hard-rubber  stem ;  an  ordinary  Albert  Smith  then 
retained  the  uterus  perfectly. 

Of  the  407  cases  of  anterior  displacements  (295  anteflexions,  112  ante- 
versions),  only  40  were  treated  with  vaginal  pessaries  (28  anteflexions,  12 
anteversions),  and  16  with  intra-uterine  stems  (5  anteflexions,  11  ante- 
flexions with  retroversion).  The  reason  why  supjDorters  were  thought 
necessary  or  beneficial  only  in  56  cases  out  of  407  of  anterior  displace- 
ment, as  compared  with  127  out  of  403  cases  of  retro-displacement  is,  that 
the  symptoms  produced  by  the  anterior  displacements  were  so  much  less 
acute  than  those  of  the  posterior  dislocations,  and  consisted  chiefly  of  dys- 
menorrhea and  sterility,  that  a  supporter  was  indicated  only  in  the  aggra- 
vated forms  and  the  flexions  were  treated  and  benefited  generally  by 
repeated  active  dilatation  by  divergent  steel  dilators.  If  the  dysmenorrhea 
was  relieved  (as  was  almost  always  the  case)  by  dilatation,  but  the  flexion 


CURABILITY    OF    UTERINE    DISPLACEMENTS.  395 

still  continued  (as  it  usually  did),  and  if  the  patient  was  married  and  sterile, 
a  pessary  was  inserted  and  worn  for  some  months.  The  stems  were  used 
only  when  the  uterus  was  so  flabby  as  to  double  over  the  anterior  border 
of  the  pessary,  or,  in  anteflexion  with  retroversion,  when  it  was  imjJossible 
to  secure  suflicient  purchase  on  the  posterior  surface  of  the  uterus,  owing 
to  the  shallowness  of  the  posterior  vaginal  pouch  and  the  rigidity  of  the 
supports,  to  elevate  the  fundus  with  a  lever-pessary  ;  in  these  cases,  the 
stem  enabled  me  to  antevert  the  uterus  and  retain  it  thus  by  a  lever-pes- 
sary with  unfailing  certainty.  Five  of  these  patients  wore  their  stem  and 
Smith  pessary  for  eleven,  five,  three,  and  two  months  (two  cases),  respect- 
ively, attending  to  all  their  marital  and  household  duties  ;  when  the  stem 
was  removed  at  the  expiration  of  the  periods  named,  the  uterus  was  found 
fairly  straight,  and  was  left  sustained  by  the  lever-pessary  in  order  to  give 
an  opportunity  for  conception.  In  none  of  these  cases,  however,  has  such 
a  result  been  as  yet  reported. 

The  pessaries  used  for  anterior  displacements  were  :  For  flexions, 
Thomas'  cup-and-hinge  pessary  (modified  by  me  by  sinking  the  originally 
projecting  hinge  so  as  to  prevent  its  indenting  the  vagina)  ;  for  versions, 
Gehrung's  double-horseshoe  pessary,  and  Thomas'  open  cup-and-hinge 
pessary,  principally  the  latter.  The  length  of  time  during  which  these 
pessaries  Avere  worn  varied  from  a  few  weeks  to  many  months  and  several 
years.  In  one  case  the  Albert  Smith  pessary  was  worn  for  one  year  and  a 
half  without  interruption  (against  my  direction),  with  the  result  of  pro- 
ducing a  deep  ulcer  behind  the  cervix.  In  two  instances  of  anteflexion  a 
slightly  curved  hard-rubber  stem-pessary  was  worn  for  eighteen  months, 
with  the  result  of  leaving  the  uterus  fairly  straight,  but  in  neither  case  has 
conception  occurred  after  a  lapse  of  two  years. 

In  five  cases  of  anteflexion,  conception  followed  repeated  rapid  dilata- 
tion and  during  the  wearing  of  a  cup-pessary  (I  am  inclined  to  attribute 
the  conception  more  to  the  dilatation  than  to  the  pessary)  ;  and  in  nineteen 
cases  of  retroversion  the  patients  became  j)regnant  while  vrearing  a  lever- 
pessary.  In  one  instance  conception  occurred  at  the  very  next  period 
after  the  sharply  retroflexed  uterus  and  the  prolapsed  ovaries  were  ele- 
vated and  retained  by  my  bulb-pessary  ;  and  pregnancy  went  on  to  tex-m. 
I  did  not  attend  the  lady  afterward  and  hence  do  not  know  whether  the 
displacement  returned.  In  only  four  of  the  cases  of  retroversion  was  it 
possible  for  me  to  see  the  patient  during  and  soon  after  confinement  (they 
both  being  under  my  obstetric  care),  and  in  all  the  uterus  was  supported 
by  a  lever-j)essary  during  the  second  week  before  they  were  allowed  to 
rise  ;  in  two  of  these  patients  the  continued  wearing  of  the  pessary  for  six 
months  longer  resulted  in  a  complete  cure  ;  in  the  other  two  it  is  still 
being  worn.  The  anteflexion  cases  did  not  return  for  subsequent  treat- 
ment, as  they  would  have  done  had  they  been  sterile  again  after  the  first 
delivery,  and  I  therefore  infer  that  practically  (not  actually)  their  distor- 
tion was  cured. 

How  many  of  these  one  hundred  and  eighty-foui'  cases  of  uterine  dis- 
placement treated  by  supports  of  one  kind  or  the  other  were  permanenlly 


396  MINOR    GYNECOLOGICAL    MANIPULATIONS. 

CUBED  I  am  unable  to  say,  for  probably  the  same  reason  that  has  prevented 
other  observers  from  collecting  positive  data,  viz.,  because  patients  who 
find  themselves  benefited  by  a  supporter,  go  on  wearing  it  for  a  while, 
finally  remove  it  themselves,  and  finding  their  relief  to  continue  without 
the  pessary,  do  not  return,  and  are  thus  lost  sight  of.  That  they  do  not 
return  is  no  proof,  however,  that  their  displacement  was  cured.  It  was 
temporarily  relieved,  the  symptoms  it  produced  gradually  disappeared, 
and  then  the  pessary  could  be  dispensed  with.  That  such  cases  were  not 
cured  is  sufiiciently  proved  by  the  constant  return  of  the  patients  months 
or  years  after  the  pessary  had  been  removed  by  themselves  or  the  physi- 
cian, with  a  return  of  the  old  symptoms,  and  on  examination  the  same  old 
displacement  is  found.  It  had  persisted  during  the  interval,  but  its  symp- 
toms had  been  temporarily  relieved.  This  holds  true  particularly  of  pos- 
terior displacements. 

Thus,  recently  a  young  lady  came  to  me  for  treatment  for  dysmenor- 
rhea, sacralgia,  and  suprapubic  pain.  I  found  a  sharp  retroflexion  of  the 
uterus,  probably  of  congenital  origin,  which  resisted  all  gentle  efforts  at 
complete  reposition.  I  gradually  replaced  it  with  a  series  of  differently 
curved  lever-pessaries,  and  then,  after  she  had  worn  the  last  pessary  for 
about  two  months,  removed  it,  as  she  expected  soon  to  return  to  her  home 
in  the  West,  the  uterus  being  perfectly  normal.  She  came  to  see  me 
again  about  two  weeks  latei-,  and  the  uterus  was  then  even  anteflexed ; 
she  was  too  well  cured,  it  seemed.  Still  she  was  told  to  come  again  in 
two  weeks,  but  remained  away  two  months,  when  a  return  of  her  old 
symptoms  brought  her  to  me  again,  and  I  found  the  original  retroflexion. 
Without  this  last  examination,  I  should  have  pronounced  her  cured  of  her 
displacement.  I  can  find  but  two  cases  of  positive  cure,  as  demonstrated 
by  occasional  examination,  of  sharp  retroflexion  ;  five  of  retroversion,  in- 
cluding the  two  treated  immediately  after  delivery  ;  three  of  anteflexion 
with  retroversion,  treated  by  the  intra-uterine  stem  and  Albert  Smith  pes- 
sary ;  and  one  of  sharp  anteflexion,  treated  by  dilatation  with  laminaria, 
steel  dilators,  and  hard  rubber  stem  during  six  months. 

I  do  not  deny  that  other  cases  may  have  been  cured,  but  I  am  as  little 
able  to  make  a  positive  statement  on  this  matter  as  the  authors  (Emmet, 
Thomas,  Barnes,  Schroeder,  etc.)  who  have  expressed  themselves  positively 
on  this  subject.  Had  all  my  cases  been  private  patients,  instead  of  a  certain 
proportion  in  the  out-door  clinic  of  a  hospital  (than  which  class  of  patients 
I  need  hardly  say  there  is  nothing  more  uncertain  and  unsatisfactory  so 
far  as  therapeutic  results  are  concerned),  I  might  have  a  better  showing. 

Luhlein,  of  Berlin,  former  assistant  to  Professor  Martin,  in  an  article 
published  in  1882,  arrived  at  substantially  the  same  conclusions  as  I  did  in 
1881,  and  I  have  seen  no  reason  to  change  my  convictions  since  then. 

Resume  op  Eules. 

A  brief  recapitulation  of  the  rules  governing  the  introduction  and  su- 
pervision of  vaginal  pessaries  (including  vagino-abdominal)  may  facilitate 
the  remembrance  of  the  directions  given  in  the  preceding  pages. 


EisUME  OF  EULE3  FOE  PESSAEIES.  397 

1.  Always  be  sure  of  the  diagnosis  of  the  nature  and  degree  of  dis- 
placement before  resorting  to  a  pessary. 

2.  Always  replace  the  uterus  before  applying  a  pessary.  This  applies 
particidarly  to  retro-displacements.  It  is  well  to  replace  the  uterus  re- 
peatedly, every  day  or  twice  daily,  for  several  days  before  introducing  a 
pessary.  The  rejDlaced  oi-gan  may  be  supported  by  cotton  tampons  in  the 
interval,  if  it  is  desired  to  distend  and  toughen  the  vaginal  pouch ;  or  the 
object  of  relaxing  the  abnormally  stretched  uterine  ligaments  may  have 
been  obtained  by  the  mere  rejjeated  replacement.  In  flexions,  chiefly 
anteflexions,  the  frequent  straightening  of  the  uterus,  or  conversion  into 
the  opposite  flexion  by  the  sound,  wiU  often  prove  beneficial  before  intro- 
ducing a  pessary. 

3.  Never  insert  a  pessary  when  there  is  evidence,  by  the  touch,  of  acute 
or  recent  inflammation  of  the  uterus  or  adnexa,  or  when  pressure  by  the 
finger  on  the  parametrium  (where  the  pessary  is  to  rest)  gives  decided  jDain. 

4.  When  the  uterus  is  not  replaceable,  that  is,  when  adhesions  bind 
the  fundus  down,  use  great  caution  and  discrimination  in  deciding  whether 
an  attempt  should  be  made  and  is  justified  by  the  symptoms,  to  elevate 
the  fundus  by  manual  or  instrumental  means,  or  whether  the  elevation 
should  first  be  tried  by  the  gi-adual  pressure  of  a  pessary  (this  applies  only 
to  retro-  and  latei'o-versions).  If  neither  is  to  be  recommended,  do  not 
introduce  a  pessary  until  local  alterative  and  absorbent  measures  (iodine 
tamponade,  hot  injections,  etc.),  have  effected  a  resolution  of  the  adhesions. 

5.  Always  choose  an  indestructible  instrument,  if  possible. 
This  does  not  apply  to  prolapsus  uteri. 

6.  Always  measure  and  estimate  the  vagina  carefully  before  choosing  a 
pessary,  and  be  careful  to  adjust  the  pessai'y  in  every  particular  (size,  curve, 
width)  to  that  particular  case.     No  two  vaginae  are  exactly  alike. 

7.  If  the  vaginal  pouch  is  not  sufficiently  deep  to  accommodate  a  pes- 
sary (anterior  pouch,  for  ante-displacements,  posterior  pouch  for  retro- 
disi)lacements),  defer  the  attempt  to  fit  a  pessary  until  the  pouch  has  been 
deepened  by  daily  tamponing  with  cotton,  or  by  the  upward  pressure  of  a 
Cutter  or  Thomas  vagino-abdominal  supporter.  Or  the  pouch  may  be 
gradually  deepened  by  using  first  a  small  (slightly  curved,  in  retro-displace- 
ment) instrument,  and  gradually  increasing  its  size  (or  curve)  until  the  de- 
sired size  and  shape  for  permanency  is  reached. 

8.  Never  leave  a  pessary  in  the  vagina  which  puts  the  vaginal  walls  to 
the  stretch,  and  which  does  not  permit  the  passage  of  the  finger  between 
it  and  the  wall  of  the  vagina.     This  does  not  npjAj  to  prolajDSus  uteri. 

9.  A  vaginal  pessary,  which  projects  from  the  vulva,  is  displaced. 

10.  A  pessary  which  gives  pain  must  be  at  once  replaced  by  one  which 
is  painless. 

11.  A  well-fitting,  properly  chosen  pessary  should  not  only  give  no 
pain,  but  should  be  a  direct  source  of  comfort  to  the  patient. 

12.  Always  examine  the  patient  on  her  feet  after  introducing  a  pessary, 
or  when  it  is  desired,  at  her  return,  to  ascertain  its  efficiency  in  sustaining 
the  uterus  during  walking  and  exertion. 


898  mi:n-or  gynecological  manipulatio:?«^3. 

13.  Always  tell  the  patient  that  she  has  a  pessaiy  in  her  vagina,  or  she 
may  not  return,  in  spite  of  your  directions,  and  the  pessaiy  may  remain 
for  years  to  her  ultimate  great  discomfort  and  danger. 

14.  Always  tell  the  patient  to  retm'n  within  a  week  after  the  fii'st  in- 
troduction, in  order  that  the  position  and  working  of  the  pessary  may  be 
looked  after,  and  that,  if  it  does  not  suit,  it  can  be  removed  and  a  better 
one  inserted.  Tell  her  that  several  trials  and  various  instruments  may  be 
required  before  one  is  found  which  she  can  wear  permanently.  Also  let 
her  return  for  inspection  once  every  four  to  eight  weeks,  as  the  case  may 
require.  Tell  her  that  if  she  fails  to  do  so  the  pessaiy  may  cause  ulcera- 
tion, for  which  treatment  will  be  needed. 

15.  Tell  the  patient  that  she  will  need  to  wear  the  pessary  for  months, 
perhaps  years,  before  a  recovery  can  be  expected. 

16.  Never  introduce  a  pessary  which  the  patient  cannot  remove  herself. 

17.  Tell  the  patient  to  remove  the  pessary  herself,  if  it  gives  pain,  and 
show  her  how  to  do  so.  ^Tien  she  has  removed  it,  let  her  present  herself 
at  once  for  examination. 

18.  Tell  the  patient  to  use  daily  vaginal  injections  for  cleansiDg  pur- 
poses. If  she  notices  j)rofuse  discharge,  add  astringents  ;  if  the  discharge 
is  sanious  or  purulent,  let  her  come  at  once,  as  the  pessary  probably  has 
caused  abrasion. 

19.  Tell  her,  on  removiug  a  pessary  to  test  the  result,  that  the  perma- 
nence of  the  benefit  obtained  therefrom  cannot  be  determined  for  several 
days  or  weeks. 

20.  Always  direct  your  patients  to  reheve  all  superincumbent  jaressure 
on  the  pessary  by  a  proper  support  of  their  skirts  ;  and  if  the  displace- 
ment be  anterior,  aid  the  internal  supporter  by  an  abdominal  (suj)rapubic) 
pad. 

All  pessaries  may  be  introduced  in  the  knee-chest  position  when  it  is 
desirable  or  possible  to  replace  the  uterus  only  in  that  position.  A  Sims 
speculum  elevates  the  perineum,  the  air  enters  and  exj)ands  the  vagina, 
and  the  pessary  (chiefly  in  retroversion  and  prolapsus)  is  introduced  by 
touch  and  sight,  and  the  patient  laid  on  her  left  side.  For  aggravated 
retroversion,  and  for  prolapsus  of  ovaries  or  uterus,  this  position  offers 
many  advantages  over  the  left  semiprone  decvibitus.  Care  must  be  taken 
to  remember  that  the  position  of  the  patient  is  reversed,  and  that  the 
pessary  must  be  introduced  accordingly. 

4.    Is'TKA-rTEPjxE  (Stem)  Pessapjes. 

Intra-uterine  pessaries  consist  of  straight  or  slightly  curved  stems  of 
various  lengths  and  diameters,  which  are  introduced  into  the  uteriue  cav- 
ity in  order  to  maintain  its  straight  direction.  They  are  comj^osed  of 
some  sohd  substance  (metal,  wood,  ivory,  glass,  hard  rubber)  or  of  soft, 
flexible  material  (soft  rubber*,  bougie,  catheter),  or  they  are  complicated, 
consisting  of  links  of  metal  (copper  and  zinc),  or  of  divergent  sjDiings  to 
insure  their  retention  in  the  uteiiis. 


INTRA-UTERINE    (sTEm)    PESSARIES. 


399 


Fig.  214.— Thomas' 
Galvanic  Stem-pessary. 


The  solid  stems  are  smooth,  slender,  round  rods,  two  and  one-eighth 
inches  in  length  (they  are  usually  one-eighth  to  one-fourth  of  an  inch 
longer  in  the  shops,  which  is  too  long),  mounted  on  a  disk,  or  cup,  or 
bulb,  which  rests  against  the  cervix  and  prevents  the  stem  from  being 
pushed  farther  into  the  uterine  canal.  The  best  are  those  made  of  hard 
rubber.  Dr.  Noeggerath  prefers  lead. 
The  sizes  vary  from  that  of  a  No.  10 
to  No.  14  bougie,  American  scale,  or 
even  larger.  The  tip  is  rounded  and 
smooth. 

The  soft  stems  are  made  of  soft 
rubber,  in  very  much  the  same  shape, 
or  of  a  bougie  or  elastic  catheter,  and 
can  be  cut  to  any  size  desired.     The 

complicated     stems,     those     which     di-  ^'G.  213.— Hard-rubber 

verge,  are  those  of  Peaslee  and  Cham- 
bers with  steel  springs,  that  of  Coxeter,  of  soft  rubber,  that  of  Thomas, 
alternate  copper  and  zinc  beads  on  a  flexible  metal  stem,  and  numerous 
others. 

There  are,  besides,  a  number  of  still  more  complicated  contrivances  de- 
signed also  to  insure  retention  of  the  stem  by  connecting  it  with  a  vaginal 
suppoi-ter ;  such  are  those  of  Kinloch  (Fig.  215),  Bp-ne  (Fig.  216), 
Thomas  (Fig.  217),  Studley,  and  Conant. 

These  combination  stem  and  vaginal  pessaries  are  generally  designed 
for  retroflexion,  but  answer  equally  well  for  any  case  where  the  stem  is 
not  retained  in  utero.  That  of  Conant  is,  2:>erhaps,  the  only  contrivance  of 
any  service  in  correcting  a  lateral  displacement.  Unfortunately,  the  fi'e- 
quent  production  of  this  displacement  by  inflammatory  conti-action  of  one 
broad  ligament  to  a  great  extent  invalidates  the  utihty  of  an  insti-ument, 
the  point  cVappui  of  which  is  the  uterine  cavity.     One  vaginal  wing  may 

be  made  larger  than  the  other 
when  it  is  desired  to  press  the 
displaced  cervix  toward  the 
other  side.  Noeggerath  has 
variously  modified  this  instru- 
ment. 

The  best  stems  are  the 
smooth  straight  ones,  and  the 
best  straight  stems  are  those  of  hard  rubber.  Stems  with  metal  divergent 
springs  are  dangerous,  and  should  not  be  used.  The  soft-rubber  inflat- 
able stems  are  less  injurious,  but  easily  become  foul.  Thomas'  galvanic 
stem-pessary  is  used  solely  for  its  stimulating  effect  in  uterine  atrophy  and 
amenorrhea.  I  have  had  excellent  results  with  it,  when  I  could  secure  its 
retention.  It  is  so  slender  as  to  escape  from  most  uteri,  but  may  be  fi:xed 
by  cotton  wads  or  a  cup-pessary. 

Of  the  utero-vagiual  combinations,  those  with  movable  connections  of 
soft  rubber,  like  Kinloch's  and  Studley 's,  are  certainly  safer  than  the  im- 


FiG.  215. — Kinloch's  Stem-pessary  for  Retrofle.xion,  with 
Staff  for  Introducing  Stem. 


400 


MINOR    GYNECOLOGICAL    MANIPULATIONS. 


movable  liard-rubber  bar  of  Byrne.  However,  tbis  immobility  of  tbe  con- 
nection between  stem-  and  lever-pessary  is  precisely  the  advantage  claimed 
by  Byrne  for  his  instrument. 

The  indications  for  the  use  of  straight  stems  introduced  into  the  ute- 
rine cavity,  and  retained  there  for  a  greater  or  lesser  time,  are  the  existence 


Fig.  216. — B3Tne''s  Stem-pe?sary  Monnterl  on  Staff  for  Introduction.     Byrne's  Vaginal  Pessary  with. 
Sliding  Crossbar  into  which  the  Stem  is  Screwed. 

of  some  distortion  of  the  canal,  which  is  irremediable  by  simple  vaginal 
supporters.  Such  distortions  (in  contradistinction  to  displacements,  viz., 
versions)  are  the  flexions,  ante-,  retro:,  and  latero-,  chiefly  those  of  con- 
genital origin,  the  ante-  and  latero-flexions.  I  have  already  stated  that 
chronic  displacements  of  the  uterus  are  only  exceptionally  cwrf^cZ  by  vagiiial 
supporters  ;  this  is  true  to  a  still  greater  degree  of  the  distortions.  The 
cure  of  a  chi'onic  anteflexion  by  a  vaginal  pessary  is  probably  still  to  be  re- 
ported. With  retroflexions  the  chances  are  better,  for  the  uterus  may  at 
least  be  straightened,  and  the  flexion  converted  into  a  version,  which  I 
have  shown  to  be  readily  remedied  and  sustained  by  a  pessary.  This  ina- 
bility to  straighten  a  sharply  flexed  uterus  by  a  vaginal  support  was  recog- 
nized by  the  earliest  advocates  of  pessaries, 
and  led  to  the  construction  by  MoUer,  in  1803, 
of  a  stem  composed  of  an  elastic  catheter 
with  flexible  wu-e  stylet,  which  could  be  bent 
to  any  desired  curve.  Amussat  followed,  in 
1826,  with  a  smooth  ivory  stem,  and  twenty 
years  later  Simpson,  Valleix,  and  Kiwisch  al- 
most simultaneously  introduced  intra-uterine 
stems.  Since  then,  the  controversy  as  to  the 
utility,  safety,  and,  indeed,  the  justifiableness 
of  intra-uterine  supports  under  any  circum- 
stances has  been  waged  with  a  vigor  and  a  diversity  of  opinion  seldom  met 
with  even  in  the  realm  of  medical  science. 

While  some  gynecologists  claim  to  have  achieved  numerous  cures  with 
intra-uterine  stems,  without  the  slightest  injury,  others  again  decry  them 
as  an  "invention  of  the  devil,"  as  utterly  unjustifiable,  and  entirely  use- 
less. 


Fig.  217.— Thomas'  Cup  Lever 
Pessary,  for  Supporting  Intra-ute- 
rine Stem. 


INTKA-UTERIXE    (sTE:m)    PESSARIES.  401 

Both  parties  contain  names  of  the  highest  eminence,  living  and  dead. 
In  order  to  give  the  reader  an  opportunity  of  judging  of  the  evidence  on 
both  sides,  I  will  reproduce  the  following  list  of  authorities  from  Chrobak  : 

Pro. — Amussat,  Simpson,  Lee,  Valleix,  Gaussail,  Yelpeau,  Kiwisch,  C. 
Mayer,  Detschy,  E.  Martin,  Yeit,  Olshausen,  Hildebrandt,  Haartmann, 
AVinckel,  Schroder,  Lewis,  Hennig,  Kristeller,  Graily  Hewitt,  Priestlev, 
Savage,  Greenhalgh,  Beatty,  Courty,  Weber,  Grenser,  Benicke,  Beigel, 
Bantock,  Chambers,  Rigb}',  Atthill,  Eouth,  etc.  To  these  may  be  added, 
Van  de  Warker,  Eklund,  Noeggerath,  Goodell,  Chadwick. 

Contra. — Depaul,  Eaciborsky,  Piorry,  Gibert,  Amussat  (later),  Ca- 
zeaux,  Scanzoni,  Hueter,  Hohl,  C.  Braun,  Seyfert,  Crede,  Freund,  Spiegel- 
berg,  Sj)aeth,  Habit,  Eetzius,  Tilt,  Meadows,  Oldham,  Bennett,  West, 
Duncan,  Tait  ;  besides,  Skene,  Byford,  Barker,  Emmet. 

A  middle  position  is  occupied  by  Schultze,  Peaslee,  Hegar  and  Kalten- 
back,  G.  Braun,  Albert  H.  Smith,  Chrobak,  Thomas,  Byrne,  Kinloch, 
Studley.  These  latter  gentlemen  do  not  wholly  discard  the  stem,  but  per- 
mit its  use  in  certain  cases  in  which  vaginal  supporters  have  utterly  failed  to 
rectify  the  distortion,  and  the  gravity  of  the  symptoms  warrants  the  use  of 
a  remedy  wdhch  may  produce  the  most  serious  results. '  Such  cases  are 
either  aggravated  anteflexion  s,  with  dysmenorrhea  and  steriHty  (whether 
such  flexions  are  congenital  or  not  is  still  a  mooted  question) ;  retroflexions, 
in  which  the  flabbiness  of  the  uterus  prevents  a  lever-j^essaiy  from  straio-ht- 
ening  the  organ  (the  retort-shaped  uterus)  ;  retroversion  of  the  anteflexed 
uterus,  in  which  the  posterior  vaginal  pouch  is  so  short  and  the  ceirix  so 
sharply  curled  up  anteriorly  as  to  afford  no  purchase  for  a  lever-pessary  ; 
lateral  displacement  not  depending  upon  cellulitis  ;  finally,  amenorrhea 
fi'om  atrojohy  or  deficient  development  of  the  uterus. 

To  specify  in  detail  the  exact  conditions  in  which  the  risk  attendin"- 
the  use  of  a  stem  is  justified,  is  scarcely  possible.  An  exclusion  of  all 
countei'-indicating  circumstances,  the  failure  of  pre\-ious  measures  for 
rectifying  the  distortion,  chief  among  which  measures  are,  of  course,  va- 
ginal pessaries,  and  the  necessity  of  relieving  the  patient,  must  formtdate 
the  indication  to  the  mind  of  each  practitioner. 

The  justifiableness  of  inserting  a  stem  simply  for  sterihty  probably 
produced  by  anteflexion  will  be  governed  by  the  same  rules  as  those  for 
other  no  less  dangerous  measures — the  dilatation  of  the  internal  os  by 
tents,  dilators,  and  the  knife.  It  is  allowable  to  let  the  patient  nm  a  cer- 
tain amount  of  risk  in  order  to  gratify  her  desire  for  maternity,  but  she 
should  be  made  acquainted  with  the  risks,  and  from  her  should  come  the 
decision. 

Counter-indications  and  Dangers. — All  inflammatory  conditions  of  the 
uterus  or  adnexa,  whether  acute  or  chronic  (except  perhaps  very  old  adhe- 

'  My  distribution  of  the  additional  names  depends  on  the  opinions  expressed  by 
their  possessors  during  the  elaborate  discussion  of  Dr.  Tan  de  Warker's  paper  on  the 
"  Intra-uterine  Stem,"  at  the  meeting  of  the  American  Gynecological  Society  in  Boston, 
in  June,  1877  (Gyn.  Trans.,  vol.  ii  ),  and  ou  their  written  or  expressed  opinions  found 
in  recent  literature. 

26 


402  MINOK    GYNECOLOGICAL    MANIPULATIONS. 

sions),  immobility  of  tlie  uterus,  extreme  tenderness  of  uterus  and  adnexa, 
endometritis  ;  uterine  hemorrhage,  pregnancy — absolutely  counter-indi- 
cate intra-uterine  stems. 

The  dangers  are  :  production  of  peritonitis  or  cellulitis,  hemorrhage, 
shock,  perforation  of  fundus  (Fallen),  any  of  which  accidents  may  be  fol- 
lowed by  death. 

The  advocates  of  stem-pessaries  claim  that  with  due  care  their  use  is 
no  more  dangerous  than  that  of  any  other  proportionate  surgical  treat- 
ment of  the  uterus,  and  admit  a  ratio  of  accidents  of  one  or  two  per  cent. 
An  occasional  death  is  reported,  but  so  has  division  of  the  cervix,  or  dila- 
tation with  sponge-tent  been  followed  by  death.  The  frequent  serious 
accidents  and  deaths  formerly  reported  (Hueter,  in  1870,  collected  twenty- 
three  deaths)  were  doubtless  due  to  carelessness  in  the  selection  of  the 
cases,  poor  instruments,  and  defective  supervision.  Noeggerath  reports 
1  case  of  hematocele,  1  of  acute  mania  in  a  hysterical  woman,  and  1  death 
from  peritonitis  in  over  100  cases ;  Winckel  found  no  death  among  247 
cases,  and  Van  de  Warker  collected  393  cases  with  but  13  serious  acci- 
dents. I  have  seen  one  case  of  pelvic  cellulitis  and  one  of  pelvic  peri- 
tonitis, both  terminating  in  recoveiy,  from  the  protracted  wearing  of  a 
jointed  Greenhalgh,  copper  and  zinc  beads,  and  a  smooth  hard-rubber 
stem,  against  positive  directions  to  remove  the  stem  by  the  attached 
strings  as  soon  as  pain  was  felt.  On  the  other  hand,  numerous  reports 
are  made  of  cases  where  the  stems  have  been  worn  for  months,  and  even 
a  year,  without  the  slightest  evil  consequences.  I  removed  a  smooth, 
hard-rubber  stem  several  years  ago  from  a  patient  with  sterility  from  retro- 
version of  the  anteflexed  uterus,  who  had  worn  it  and  a  lever-pessary  for 
over  five  months  without  the  slightest  disturbance  or  interference  with  her 
menstrual  or  marital  functions.  It  was  removed  simply  in  order  to  test 
the  position  of  the  uterus  and  her  capability  of  conception.  Kecently  I  re- 
moved slightly  curved  hard-rubber  stems  from  two  ladies  who  had  worn  them 
uninterruptedly  since  their  introduction,  respectively  eighteen  and  twenty 
months  before  in  Germany.  The  stems  were  inserted  for  dysmenorrhcea 
and  sterility,  the  former  of  which  was  relieved,  and  were  removed  to  test 
the  permanency  of  the  benefit  and  the  possible  influence  on  the  sterility. 
In  one  recent  case  of  obstinate  retroflexion,  the  stem  was  worn  for  over 
four  months,  and  then,  for  some  unknown  reason,  gave  pain  ;  the  jpatient 
continuing  to  wear  it,  contrary  to  positive  direction  ;  a  large  plastic  exuda- 
tion of  cellulitic  and  peritonitic  nature  took  place,  after  the  absorption  of 
which  the  uterus  was  found  bound  down  by  adhesions.  At  the  earnest 
sohcitation  of  the  patient,  who  was  made  fully  aware  of  the  risk,  some  six 
months  after  the  exudation  had  disappeared,  the  uterus  was  forcibly  ele- 
vated under  chloi'oform,  a  lever-pessaiy  was  first  introduced,  and  no  re- 
action ensuing,  a  week  later  a  hard-rubber  stem,  both  of  which  have  now 
been  worn  without  discomfort  for  nearly  a  year. 

While  there  are  certain  cases  in  which  nothing  will  do  as  much  good 
as  a  stem-pessary,  and  nothing  will  straighten  the  canal  but  a  stem,  and  in 
which  we  are  therefore  justified  in  using  it,  we  should  always  carefully 


INTRA-UTERINE    (sTEM)    PESSAEIES.  403 

weigh  the  benefits  and  risks  before  deciding  to  insert  it,  and  remember 
that,  however  tolerant  the  endometrium  may  be  of  momentary  insults,  it 
occasionally  resists,  with  great  violence  any  permanent  irritation.  And 
even  the  smoothest  stem  will  prove  an  iriitant  to  many  uteri. 

The  question  may  be  summed  up  by  saying  that,  while  certain  cases 
will  react  disagreeably  against  the  introduction  or  retention  of  a  stem-pes- 
sary, the  majority  will  bear  it  well,  if  the  proper  precautions  (to  be  enumer- 
ated hereafter)  are  observed. 

Chrobak  puts  the  question  very  fau-ly  as  follows  :  "Not  ha\'ing,  in  the 
relatively  small  number  of  cases  in  which  I  emj)loyed  the  intra-uterine 
stem  (35),  seen  markedly  better  results  than  from  other  measures,  I  have 
gradually  restricted  its  use,  although  I  must  admit  that  I  do  not  consider 
the  stem-pessary,  with  proper  caution,  a  specially  dangerous  instrument, 
and  permit  its  use  when  all  other  treatment  has  failed  and  the  severity  of 
the  symptoms  justifies  a  treatment  not  quite  free  from  danger."  Person- 
ally, I  am  convinced  that  the  stem  could  be  used  with  great  advantage  in 
very  many  cases,  chiefly  aggravated  anteflexion,  if  it  were  always  intro- 
duced at  the  home  of  the  patient,  under  anesthesia,  and  the  patient  kept 
in  bed  for  at  least  a  week  after. 

The  precautions  to  be  scrupulously  observed  in  the  use  of  stem-pessaries 
are  the  following :  1.  Carefully  exclude  all  counter-indicating  circum- 
stances. 2.  Always  choose  a  stem  which  is  at  least  one-fourth  inch  shorter 
than  the  uterine  cavity,  the  exact  length  of  which  should  have  been 
measured  by  sound  or  probe.  The  majority  of  stems  sold  in  the  stores  are 
at  least  one-fourth  of  an  inch  too  long,  and  consequently  press  upon  the 
fundus.  If  a  shorter  stem  had  been  used,  the  accident  reported  by  Dr. 
Fallen  of  perforation  of  the  fundus  through  the  stem  being  driven  into  it 
by  a  sudden  fall,  could  not  have  occurred.  3.  Use  only  a  smooth  instru- 
ment, without  springs.  The  soft-rubber  stems  of  Coxeter,  Squarey,  and 
others,  are  exceptions  to  this  rule,  as  also  the  galvanic  stem  of  Thomas, 
which  is  intended  to  irritate.  4.  Always  insert  the  stem,  if  possible, 
at  the  house  of  the  patient,  under  anesthesia  if  pi-evious  dilatation  is  to 
be  employed,  and  keep  the  patient  in  bed  for  at  least  one  week.  5.  At- 
tach a  cord  to  the  bulb  of  the  stem  and  tell  the  j^atient  to  remove  it, 
if  she  experiences  the  slightest  suprapubic  or  pelvic  pain,  which  continues 
longer  than  a  few  minutes.  6.  Tell  the  patient  to  avoid  violent  exer- 
cise, lifting,  sexual  intercoiirse,  until  the  stem  has  been  worn  at  least  sev- 
eral weeks  and  a  tolerance  has  been  established.  7.  See  her  often  and 
watch  her  cai-efully  ;  as  Goodell  says,  and  he  is  an  ardent  advocate  of  the 
stem  under  the  precautious  here  enumerated,  "  this  instrument  is  a  good 
one,  a  very  good  one — to  watch." 

The  results  of  the  treatment  by  intra-uterine  stems  have  been  faii'ly 
expressed  by  Chrobak  in  the  above  quotation.  Whether  old  sharp  flex- 
ions are  ever  cured  by  the  prolonged  straightening  of  the  canal  with 
a  stem,  is  still  undecided.  If  the  stem  chances  to  produce  just  sufiicient 
irritation  to  thicken  the  angle  of  flexion,  a  cure  may  result,  but  this  ex- 
act hmit  is  difficult  to  obtain.     We  may  either  irritate  too  little  or  too 


404        MINOR  GYNECOLOGICAL  MANIPULATIONS. 

much.  As  regards  sterility  and  dysmenorrliea,  the  results  are  better. 
Strange  to  say,  conception  has  even  taken  place  with  a  stem  in  utero,  and 
the  o-estation  has  in  most  instances  gone  on  to  term.  Winckel,  Olshausen, 
Goodell,  and  others,  report  cases,  some  twelve  or  fifteen  altogether,  I  be- 
lieve. Of  course,  the  stems  in  these  cases  did  not  possess  the  broad  cup 
for  the  cer-sTix  shown  in  Fig.  213,  but  merely  a  small  bulb  to  prevent  its 
slipping  into  the  os.  The  cui-e  of  dj'smenorrhea,  depending  on  stenosis  of 
the  uterine  canal  by  prolonged  wearing  of  a  stem,  is  not  uncommon. 
Amann  reports  nine  cures  in  sixteen  cases,  and  I  have  seen  quite  a  number 
in  my  own  practice. 

3Iode  of  Introduction. — The  exact  dimensions  and  curve  of  the  uterine 
canal  must  first  be  ascertained  by  the  sound ;  especially  must  the  length 
of  the  canal  froin  external  os  to  fundus  be  carefully  measured.  A  stem, 
corresponding  in  thickness  and  length  to  the  canal,  is  then  chosen.  I  have 
already  expressed  my  preference  for  the  smooth,  hard-rubber  stem,  of 
which  there  are  several  sizes.  Special  care  should  be  taken  to  have  the 
stem  at  least  one-eighth  of  an  inch  shorter  than  the  uterine  canal,  measur- 
ing from  the  bottom  of  the  cervical  cup.  A  stout  cord,  six  inches  long,  is 
tied  about  the  base  of  the  stem,  to  enable  the  patient  herself  to  remove  it. 
The  stem  is  best  introduced  through  Sims'  speculum. 

The  cervix  being  seized  by  the  tenaculum,  the  uterus  is  drawn  down 
and  straightened,  and  the  stem,  impaled  on  a  sponge-tent  expeller  or  slide- 
applicator,  is  inserted  into  the  os  and  pressed  upward,  exactly  as  a  lamina- 
lia  or  tupelo-tent  would  be.  If  the  canal  is  sufficiently  large,  no  difficulty 
is  experienced  in  passing  the  stem  up  until  the  cervix  rests  in  the  cup. 
But,  if  there  is  an  obstacle  at  the  internal  os,  the  steel-branched  dilator 
may  be  passed  thi'ough  it,  and  the  canal  dilated  as  far  as  seems  neces- 
sary. If  there  is  difficulty  in  causing  the  straight  stem  to  follow  the 
curve  of  the  canal,  the  sound  may  be  introduced,  and  by  its  side  a  fine 
probe  ;  the  sound  is  then  withdrawn  and  the  stem  inserted  along  the 
probe  as  a  guide,  which  is  then  removed.  In  some  cases  I  have  found 
it  impossible  to  force  the  stem  through  the  angle  of  flexion  through  a 
Sims  speculum,  but  have  succeeded  easily  by  putting  the  patient  on  her 
back,  and  manipulating  the  fundus  uteri  with  the  external  hand  until  I 
had  straightened  the  uterus,  the  stem  in  the  cervical  canal  being  at  the 
same  time  guided  and  supported  by  the  internal  finger  ;  as  soon  as  the 
canal  was  straight  the  stem  was  pushed  up  and  the  fundus  down,  and  its 
insertion  at  once  accomplished.  I  have  found  that,  under  such  circum- 
stances, I  could  succeed  better  without  an  applicator,  merely  guiding  the 
stem  into  the  cervix  with  my  fingers,  and  manipulating  the  uterus  be- 
tween both  hands.  As  soon  as  the  stem  has  reached  the  fundus,  it  is  slid 
off  from  the  applicator,  and  the  speculum  removed.  Care  must  be  taken 
to  allow  the  cord  to  project  slightly  from  the  vagina.  The  cup  or  bulb 
should  always  fit  tightly  over  the  os.  If  the  stem  is  introduced  for  ante- 
flexion, no  support  is  needed  to  prevent  its  esca^^e  ;  the  cervix  will  rest 
against  the  posterior  vaginal  wall,  and  I  have  never  seen  a  stem  escape 
when   the  uterus  was  anteverted.      If    it  shows  a  tendency  to  retrovert, 


INTRA-UTEEINE    (sTEM)    PESSARIES.  403 

however,  some  support  must  be  given  to  the  bulb  of  the  stem,  and  this 
may  be  done  either  by  a  lever-pessary  with  a  cup  between  its  bars  (Fig. 
217)  or  by  attaching  the  stem  to  a  lever-pessary  by  a  rubber  band  (Fig. 
215),  or  by  fixing  it  in  a  movable  hard-rubber  slide  (Fig.  216).  Supports 
which  are  immovably  connected  with  the  stem  are,  in  my  opinion,  more 
dangerous  than  those  in  which  an  elastic  rubber  band  or  hinge  permits  the 
uterus  to  move  about  with  every  motion  of  the  diaphragm.  The  stem  may 
either  be  inserted  first  and  the  vaginal  pessary  second,  which  is  best 
done  through  a  Sims  speculum,  or  the  lever-pessary  is  first  introduced  as 
above  described,  and  then  the  stem  through  the  speculum.  The  difficulty 
of  bringing  the  retro-displaced  cervix  properly  into  reach,  renders  the  latter 
method  less  desirable.  I  have  frequently  introduced  both  stem-  and  lever- 
pessary  without  a  speculum,  taking  care  not  to  dislodge  the  cup  or  bulb 
of  the  stem  while  slipjDing  the  lever  into  the  posterior  vaginal  pouch.  As 
a  rule,  I  have  found  it  unnecessary  to  connect  the  stem-  with  the  lever- 
pessary  at  aU,  since,  if  the  latter  did  its  work  Avell  and  anteverted  the 
uterus,  the  jDosterior  vaginal  wall  retained  the  stem  by  itself.  I  have  had 
both  pessaries  worn,  without  being  connected,  for  months,  and  neither  be- 
came disjDlaced.  In  retroversion  of  the  anteflexed  uterus,  this  combina- 
tion of  stem-  and  lever-pessary  is  the  most  satisfactory  method  of  lifting 
up  the  fundus  and  straightening  the  uterus.  Some  gynecologists  (Schi'oe- 
der  and  Amann)  keep  the  uterus  anteverted  for  a  few  days  by  packing  the 
anterior  vaginal  vault  with  cotton. 

The  introduction  of  a  stem-pessary  should  be  as  carefully  performed  as 
that  of  the  sound.     Only  a  size  which  wiU  readily  pass  should  be  chosen. 

To  remove  a  stem  it  is  only  necessary  to  hook  the  point  of  the  index- 
finger  into  the  cup,  or  press  it  gently  from  side  to  side  until  it  becomes 
loosened,  and  then  gently  withdraw  it.  An  oozing  of  bloody  mucus  may 
follow  its  removal.  Until  the  patient  has  become  used  to  the  stem,  it 
should  be  removed  before  each  menstrual  joeriod,  and  reintroduced  after 
the  flow.  Later  on,  it  is  not  necessary  to  remove  it.  In  the  beginning  the 
flow  vdU  probably  be  somewhat  increased,  but  only  a  very  decided  increase 
will  in  itself  demand  the  removal  of  the  stem.  The  straightening  of  the 
uterine  canal  during  meustrviatiou  often  causes  the  stem  to  slijD  out  of  the 
uterus.  Coition  should  be  2:)rohibited  until  tolerance  to  the  stem  is  assured. 
It  is  obvious  how  impetuous  coition  might  injure  the  fundus  uteri,  and 
gentleness  is  therefore  imperative  at  aU  times. 

How  long  a  stem  may  need  to  be  worn  can  scarcely  be  determined  be- 
forehand. The  answer  might  be,  as  long  as  the  patient  can  bear  it.  "We 
can  confidently  expect  to  find  no  permanent  improvement  before  six 
months,  probably  not  before  one  year.  And  it  has  ah-eady  been  stated 
how  improbable  it  is  that  the  patient  will  be  able  to  wear  the  stem  so 
long.  Usually,  in  outdoor  patients,  before  many  months  have  passed, 
some  indiscretion,  some  exertion,  or  accidental  circumstance,  will  have 
brought  about  pelvic  pain  or  peritoneal  ii-ritation  or  ovarian  congestion 
(most  commonly)  and  the  stem  is  removed,  because  the  physician  very 
wisely  dechnes  to  take  the  risk  of  increasing  these  possibly  premonitory 


406  MINOE    GYNECOLOGICAL    MANIPULATIONS. 

signs  of  e\dl.     Uterine  catarrh  is  one  of  the  common  results  of  long-con- 
tinued wearing  of  a  stem-pessaiy. 

Several  rules  should  always  be  observed,  and  they  are  to  keep  watch 
of  the  patient,  see  her  frequently,  and  from  time  to  time  remove  the  stem 
only  to  reintroduce  it  at  once,  if  all  is  right  (as  shown  by  bimanual  examina- 
tion) ;  tell  her  to  avoid  unusual  exertion,  and  to  remove  it  at  once  by  the 
attached  string  (which  should  be  left  until  the  first  menstrual  period  is 
passed,  at  least,  when  it  will  have  become  ofi:ensive)  if  she  experiences  ab- 
dominal pain,  or  if  profuse  hemorrhage  comes  on.  A  disregard  of  this 
direction  will  probably  result  in  inflammation,  as  occurred  to  the  patients 
of  mine  aheady  referred  to. 


XIIL  THE  HYPODERMIC  INJECTION  OF  ERGOT. 

Ergot  has  been  injected  under  the  skin  for  uterine  hemorrhage  post- 
partum and  for  fibroid  tumors  many  thousand  times  since  Hildebrandt 
first  published  his  experience  with  this  treatment  in  1874.  To  give  a  nu- 
merical account  of  all  the  cases  thus  treated,  with  the  results  of  successes 
and  failures  would  be  impossible,  because  a  large  portion  of  the  cases  have 
never  been  reported.  The  beneficial  influence  of  ergot  injected  under  the 
skin  in  subduing  uterine  hemorrhage  depending  on  interstitial  and  sub- 
mucous fibroids,  on  subinvolution  and  hj-perplasia  of  the  uterus,  has  been 
acknowledged  beyond  dispute,  as  also  the  failure  of  this  treatment  in 
many  cases  when  the  fibroid  was  subperitoneal,  or  exceedingly  dense,  or 
surrounded  by  a  very  thin  shell  of  muscular  tissue,  or  when  the  uterus 
was  in  the  stage  of  induration. 

In  subinvolution  and  areolar  hyperjolasia  this  method  has  not  become 
as  popular  as  for  fibroids,  and  still  it  seems,  from  observations  made  by  so 
competent  and  reliable  an  observer  as  Leopold,  of  Dresden,  that  much  good 
can  be  done  by  a  systematic  course  of  ergot-injection  in  these  obstinate 
cases.  This  author  treated  eight  cases  of  uterine  subinvolution,  five  of 
hyperplasia,  and  one  of  membranous  dysmenorrhea,  with  hypodermics  of 
ergot,  and  found  decided  benefit  as  regards  diminution  of  menorrhagia 
and  reduction  in  size  of  the  uterus,  and  in  the  dysmenorrhea  case  a  tem- 
porary cessation  and  permanent  decrease  in  quantity  of  the  exfoHation 
from  the  treatment.  In  subinvolution  and  hyperplasia,  the  treatment 
lasted  from  three  weeks  to  foui-teen  months,  the  average  being  about  three 
months,  and  from  ten  to  one  hundred  and  four  injections  were  made,  the 
average  being  about  forty  to  each  patient.  Only  once  did  the  puncture 
produce  an  abscess.  When  fifty  to  sixty  injections  had  been  given  with- 
out special  benefit,  Leopold  found  that  a  continuance  was  not  likely  to 
be  of  particular  use.  Whatever  result  was  to  be  expected  was  surely  ob- 
tained, wholly  or  in  part,  by  that  time.  Leopold  agrees  with  the  results  of 
Hildebrandt  as  regards  the  effects  of  this  treatment  for  fibroids,  having  in 
twelve  cases,  with  an  average  of  sixty  injections,  obtained  a  decided  im- 
provement in  seventy-five  per  cent.,  and  no  benefit  only  in  twenty-five  per 


THE    HYPODERMIC    INJECTIOIS"    OF    ERGOT.  407 

cent.  Hildebrandt's  figures  were  twenty  per  cent,  cured,  sixty-four  per 
cent,  improved,  and  sixteen  per  cent,  not  benefited.  The  results  of  8cau- 
zoni  and  Chrobak  are  not  so  good,  being  but  forty-five  per  cent,  improved, 
and  fifty -five  per  cent,  not  benefited,  none  entirely  cured.  A.  Martin,  of 
Berlin,  even  has  the  discouraging  figures  of  one  hundred  not  benefited. 
Enough,  however,  has  ah'eady  been  written  on  this  subject  by  various 
authors  to  show  that  the  hemorrhage  in  fibroids  (interstitial  and  sul:)mu- 
cous  only)  can  be  at  times  greatly  reduced  and  the  size  of  the  growth  di- 
minished by  a  persistent  employment  of  this  treatment.  And  that  some 
benefit  is  to  be  expected  in  subinvolution  and  hyperjDlasia  (so  long  as  the 
stage  of  induration  is  not  reached)  is  shown  by  the  obseiwations  of  Leo- 
j)old. 

Manner  of  Performing  the.  Injection. — The  two  great  objections  to  this 
treatment  are,  1,  the  pain  which  the  injections  give  ;  and  2,  the  cellular 
inflammation,  and  possibly  suppui-ation,  which  frequently  follow  at  the 
seat  of  puncture. 

To  avoid  these  unpleasant  symptoms  several  precautions  should  be  ob- 
served : 

1.  A  perfectly  fresh  solution  of  ergot.  I  have  always  used  (and  be- 
lieve it  to  be  as  good  as  any  other  more  complicated  one)  a  solution  of 
Squibb's  semi-solid  aqueous  extract  of  ergot,  one  grain  to  two  minims  of 
water,  with  the  addition  of  one  grain  of  salicylic  acid  to  the  drachm  of 
solution  if  it  is  to  be  kept.  Every  two  minims  of  this  solution  thus  con- 
tain one  grain  of  ergot,  and  if  twenty  minims  are  injected  the  patient  gets 
ten  grains  of  ergot  (equal  to  the  same  amount  of  the  so-called  ergotine)  at 
each  injection — quite  as  much  as  should  be  given  at  one  sitting,  if  the 
injections  are  to  be  frequently  repeated.  This  solution  will  readily  flow 
through  the  ordinary  hyjDodermic  needle. 

2.  The  injections  should  be  made  in  a  radius  about  the  umbilicus,  ex- 
tending not  more  than  six  inches  from  that  j^oint  as  a  centre,  chiefly  below 
it.  This  is  a  much  better  point  than  the  thigh,  which  I  have  seen  recom- 
mended, and  where  a  possible  inflammation  will  interfere  with  Avalkiug 
and  sitting. 

3.  The  injection  should  be  performed  in  a  j^articular  manner,  the  skin 
being  lifted  up  by  two  fingers  of  the  left  hand  to  the  height  of  at  least 
two  inches,  and  the  needle  then  thrust  in  to  its  hilt  so  as  to  carry  the  fluid 
into  the  subcutaneous  cellular  tissue,  or  even  into  the  substance  of  the 
muscle.  This  is  a  point  of  the  greatest  importance,  and  pain  and  inflam- 
mation will,  to  a  great  extent,  be  avoided  thereby.  Even  a  hypodermic  of 
morphine  will  produce  a  dermo-cellulitis  if  the  fluid  in  injected  into  the  sub- 
stance of  the  skin  itself  The  fluid  shovdd  be  injected  slowly,  and  no  fear 
need  be  entertained,  with  ordinary  care,  of  penetrating  the  abdominal 
wall. 

4.  Always  make  the  injections  at  the  home  of  the  patient,  and  keep  her 
quiet  in  bed  for  several  hours  afterward,  with  cold-water  compresses  over 
the  puncture,  until  experience  has  shown  that  she  bears  the  treatment 
weU, 


408  MIXOE    GYNECOLOGICAL    MANIPULATIONS. 

5.  Some  pain,  redness,  and  even  infiltration  will  follow  the  majority  of 
injections,  but  nothing  more,  if  these  rules  be  observed.  I  have  even  in- 
jected a  whole  syringeful  of  Squibb's  fluid  extract  of  ergot  for  post-partum 
hemorrhage,  and  have  but  once  seen  an  abscess  result  therefrom, 

6.  Accordingly  as  the  injections  are  borne,  they  may  be  made  every 
other  or  every  third  day,  and  they  should  be  continued  for  months  if  any 
benefit  is  to  accrue  from  this  treatment. 


PAET    III. 
GYXECOLOGICAL    OPEEATIOX 


GY.^'EEAI.   COXSEDEEATIOVS, 

0>'   THE  BEST  TEVIE    FO?.    OPEEATES'G-  :    OX   PEEP  A  HA  TORY  a2hT)  AFTER- 
treatment:  ;   02f  the  aUTURE  :   OX  DISTSTECTIOX  ;   OX  AXEcsTHEi^IA. 


L  Thz  litST  Tnm  yob.  OpiSircsG. 

The  best  time  for  the  performance  of  an  opera-tioii  on  the  female  genital 
organs  is  ixndoubtedly  during  the  first  or  second  week  after  the  cessa- 
tion of  the  menstrual  jiow.  It  is  fae  resxilt  of  experience,  a  resnlt  entirelT 
in  accordance  with  physiology  and  logic,  that  the  general  hyperemia  and 
hyperesthesia  (or,  better,  hypemeurosis  >  normally  present  inn  mediately 
before  and  during  the  regular  menstrual  cyde  renders  the  possibiiitj 
of  inflammatory  reaction  and  hemorrhage  greater  after  an  operation  un- 
dertaken at  or  near  that  epoch  than  in  the  intermenstrual  period.  It  is 
therefore  advisable  to  choose  a  date  sufficiently  distant  from  the  last 
period  to  avoid  these  dangers,  and,  on  the  other  hand,  not  so  near  the  nest 
period  as  to  incur  the  risk  of  the  not-yet-healed  wound  being  injutiouslT 
affected  by  the  then  returning  hyperemia. 

It  is  rare  for  a  healthy  wound  to  recj^uire  more  than  one  week  for  its 
perfect  healing,  and  if  its  edges  have  been  well  adapted  and  the  circum- 
stances are  favorable  to  union  by  the  first  intention,  that  fortunate  result 
is  usually  attained  within  the  first  forty-eight,  and  permanently  secured 
after  ninety-six  hours.  The  recurrence  of  the  menstrual  congestion  and 
flow  after  the  Litter  period  will  rarely  injure  the  freshly  healed  wound,  even 
though  the  operation  have  been  one  on  the  cervix  uteri  or  the  perineum. 
A  week  of  perfect  vascular  and  nervous  rest  must,  therefore,  ordmarilT 
suffice  to  iasure  permanent  union  :  but  in  view  of  the  tendency  to  inflam- 
mation and  suppuration  of  cellular  tissue  in  the  vicinity  of  wounds,  and  of 
possible  septic  infection  even  at  a  kte  day,  it  is  usually  advisable  to  have 
at  least  two  weeks'  freedom  from  menstrual  excitement  for  every  operation 
in  or  about  the  female  genitals.  If  a  woman  is  regularly  "  unwell ""  every 
twenty-eight  days,  and  her  period  averages  fire  to  seven  days,  die  has  about 


410  GYNECOLOGICAL    OPERATIOITS. 

twenty-one  days  of  intermenstrual  rest.  Of  these,  three  must  be  deducted 
at  the  end  of  the  last  and  three  just  before  the  beginning  of  the  nixt 
period,  in  order  to  avoid  a  possible  recurrence  or  premature  appearance  of 
the  flow  from  the  excitement  of  the  operation,  and  we  have  at  least  fifteen 
days  at  our  disposal,  quite  sufficient  for  even  the  largest  operation  in  gyne- 
cological surgery,  ovariotomy,  or  laparo-hysterectomy.  Only  in  case  of 
prolonged  convalescence  might  the  menstrual  hyperemia  produ^je  febrile 
exacerbations  after  the  fifteenth  day  from  the  operation. 

If  feasible,  then,  an  operation  should  be  fixed  for  the  tHrd  day  after  the 
complete  cessation  of  the  menstrual  flow,  and,  ordinarily,  not  later  than 
the  tenth  day.  In  case  of  ru-gency,  the  risk  may  certainly  be  taken  of 
operating  at  so  late  a  day  as  to  render  the  inception  of  the  flow  probable 
before  the  stitches  are  removed.  In  that  case  it  is  by  all  means  advisable 
to  await  the  cessation  of  the  discharge  before  removing  the  stitches,  in 
order  that  the  fresh  union  may  not  be  disturbed  by  tha  congestion  natural 
to  the  menstrual  epoch,  or  by  the  forcing  of  blood  between  the  stitches. 

The  time  of  year  most  favorable  for  operations  is  undoubtedly  the  au- 
tumn, early  winter,  and  early  summer.  The  last  half  of  the  winter,  par- 
ticularly the  months  of  February  and  March,  is  the  least  favorable  ;  at  this 
season,  not  only  has  the  health  of  mankind  in  general,  especially  in  cities, 
become  deteriorated  by  the  labors,  excitements,  and  dissipations  of  the  past 
winter,  but,  with  the  melting  of  the  snow,  endemics  of  contagious  and  in- 
fectious diseases  (scarlatina,  measles,  diphtheria,  puerperal  fever,  erysipe- 
las) are  more  prevalent.  Besides,  in  hospitals,  the  more  or  less  confined 
wards  have  gradually  become  contaminated,  in  spite  of  ventilation  and 
disinfection,  through  the  accumulation  of  miasms  and  gases,  and  a  con- 
dition unfavorable  to  the  speedy  union  of  wounds,  known  as  hospitalism, 
manifests  itself.  It  is  not  uncommon  for  the  surgeons  of  some  hospitals 
to  entirely  desist  from  operating  during  such  a  time,  until  by  thorough 
disinfection  the  taint  has  been  eradicated.  For  this  very  reason  one  of  our 
best  hospitals,  the  New  York  Woman's  Hospital,  closes  its  doors  to  pa- 
tients from  July  1st  to  September  1st  of  each  year. 

In  the  summer  months  wounds  generally  heal  very  well,  and  there  is 
no  objection  to  operating  on  that  score.  But,  in  our  climate,  the  usual 
intense  summer  heat  renders  a  sojourn  of  several  weeks  or  longer  in  bed 
exceedingly  irksome  to  most  patients,  and  all  postponable  operations  are 
therefore  usually  deferred  till  cooler  weather. 

Whenever,  at  any  time  of  year,  there  appears  to  be  in  a  certain  com- 
munity a  disjDOsition  for  wounds  to  heal  badly,  or  an  endemic  of  infectious 
diseases  springs  up,  it  is  best  to  defer  operations  until  the  often  undefined 
danger  is  past.  Still,  with  careful  antisepsis,  even  rmder  such  circum- 
stances, good  results  can  be  achieved,  especially  in  private  practice.  Thus, 
in  the  month  of  March,  1882,  when  puerperal  septicemia  was  raging  (I 
myself  saw  five  cases  in  consultation  during  that  month),  when  the  Wom- 
an's Hospital  was  closed  to  operations  on  account  of  the  recent  uniform 
bad  results,  and  when  even  minor  plastic  operations  in  the  city  did  badly, 
I  hajopened  to  perform  eleven  operations  in  my  private  practice  (one  ovari- 


THE    BEST    TIME    FOR    OPERATIITG.  411 

• 

otomy,  three  cervix  lacerations,  three  secondary  perineorrhaphies,  one 
cystocele  operation,  one  excision  of  vaginal  cyst,  one  removal  of  fibrous 
polypus,  one  amputation  of  cer\'ix  by  galvano-cautery  wire),  and  aU  did 
perfectly  well,  with  the  exception  of  one  case  of  perineorrhaphy,  which  de- 
velojDed  a  pneumonia,  from  which  the  patient  recovered  with  a  perfect 
perineum. 

This  sj)ecies  of  "  genus  epidemicus  "  is  far  more  likely  to  rage  in  a 
crowded  city  than  in  the  country. 

When  to  perform  an  oper'ation  on  a  pregnant  or  2^uer2Deral  ivoman  is  a 
question  of  some  importance. 

The  indication  for  the  performance  of  an  operation  on  a  pregnant 
woman,  whether  on  her  genital  organs  or  on  any  other  portion  of  her  body, 
will  depend  entirely  on  the  urgency  for  interference  and  the  danger  of 
waiting  until  after  delivery.  In  the  case  of  some  disease  which,  if  allowed 
to  proceed  undisturbed,  may  prove  fatal  before  the  end  of  pregnancy  (such 
as  cancer  of  the  bi*east,  cervix,  external  genitals,  or  of  any  organ  where  its 
surgical  removal  is  feasible) ;  or  of  an  affection  the  existence  or  growth  of 
which  may  interfere  seriously  with  delivery  (such  as  ovarian  and  uterine 
tumors,  contraction,  malignant  or  benign,  of  the  cervix,  vagina,  or  vulva, 
tumors  of  the  external  genitals),  any  immediate  operation  may  be  indi- 
cated, in  spite  of  the  risks  which  may  attend,  both  as  regards  the  interrup- 
tion of  pregnancy  and  the  occurrence  of  septic  infection  in  that  particu- 
larly susceptible  condition.  Thus,  amputation  of  an  extremity,  excision  of 
the  breast,  removal  of  the  cancerous  cervix,  or  of  an  ovarian  tumor  or 
fibroid  polypus,  or  a  hypertrophy  of  the  external  genitals,  have  been  suc- 
cessfully performed  on  women  in  various  stages  of  pregnancy.  I  have 
even  assisted  at  an  operation  for  closure  of  a  lacerated  cervix,  in  which  the 
pregnancy  (unsuspected,  or  the  operation  would  not  have  been  done)  went 
on  to  term.  In  a  similar  case  of  my  own,  however,  and  in  one  of  amputa- 
tion of  the  cancerous  cervix,  the  pregnancy  also  being  unsuspected,  abor- 
tion took  place.  I  have  also  partially  excised  a  cyst  in  the  anteiior  vaginal 
wall,  and  split  and  cauterized  an  abscess  of  the  Bartholinian  gland  and  re- 
moved an  epithelioma  of  the  posterior  lip  of  the  cervix  during  the  earlier 
months  of  pregnancy  without  injury  to  that  condition. 

The  nearer  the  seat  of  the  operation  is  to  the  uterine  cavity  the  more 
likely  is  an  interruption  of  the  pregnancy. 

Operations  on  parts  which  are  Hable  to  be  torn  again  during  the  forth- 
coming delivery  should  not  be  performed  during  pregnancy.  Such  are 
those  for  lacerated  cervix  and  perineum,  which  should  be  deferred  until 
after  delivery,  no  matter  how  annoying  these  lesions  may  be.  Profuse 
cervical  leucorrhea  and  prolapse  of  the  vaginal  walls  (rectocele  and  cysto- 
cele), both  of  which  are  very  common  occun-ences  during  pregnancy,  should 
be  palliatively  treated  by  astringent  tampons  and  the  woman  made  com- 
paratively comfortable  until  after  confinement. 

How  soon  after  confinement  may  a  ivoman  be  operated  on  for  some  lesion 
of  her  genital  organs  ?  The  normal  period  of  involution  of  these  organs 
should  always  be  allowed  to  expire  before  performing  an  operation  on 


412  GYNECOLOGICAL    OPERATIONS. 

them.  If  a  lacerated  cei-vix  or  perineum  requires  sti telling  (these  being  the 
usual  operations  called  for  in  consequence  of  and  after  dehvery),  the  op- 
ieration  should  be  deferred  until  at  least  two  months  have  elapsed  after 
confinement  and  the  tissues  have  regained  their  ante-puerperal  condition 
as  to  vascularity  and  reparative  power.  Before  the  end  of  the  second 
month  the  frequent  persistence  of  the  lochial  discharge  might  interfere 
with  union,  and  the  succulence  and  hyperemia  of  the  parts  naturally  per- 
sisting after  pregnancy  must  lead  to  a  cutting  through  of  the  sutures.  As 
soon  as  cicatrization  of  the  wound  has  taken  place,  or  the  torn  surfaces 
have  assumed  a  pale,  but  slightly  secreting  character,  the  time  for  the 
operation  has,  ceteris  paribus,  arrived. 

It  must  not  be  supposed  that  lactation  will  interfere  unfavorably  either 
with  the  success  of  the  operation  or  the  nutrition  of  the  infant.  Trache- 
lorraphy  is  but  rarely  followed  by  constitutional  or  local  disturbance  of 
any  kind,  and  perineorraphy,  if  healing  proceeds  favorably,  does  not  inju- 
riously affect  the  character  of  the  milk.  The  only  precautions  to  be  ob- 
served are  not  to  apply  the  child  to  the  breast  for  twenty-four  hours,  when 
all  traces  of  the  anesthetic  will  have  disappeared,  and  to  observe  even  more 
than  the  usual  cleanliness  about  the  Avound  to  avoid  possible  absorption  of 
septic  material. 

Particularly  as  regards  laceration  of  the  perineum,  I  think  an  early 
operation  advisable,  in  order  that  the  injurious  effects  of  the  loss  of  sup- 
port of  the  vagina  and  uterus  (rectocele,  cystocele,  descensus,  retroversion, 
chronic  leucorrhea)  may  be  anticipated.  Lacerations  of  the  cervix  are  sel- 
dom recognized  soon  after  delivery,  for  the  reason  that  but  few  general 
practitioners  examine  a  woman  either  immediately  after  labor  or  before 
discharging  her  fi'om  observation,  and  thus  do  not  become  aware  that  the 
cervix  was  torn  until  later  symptoms  again  direct  the  patient  to  them,  or 
a  specialist  is  consulted.  While  I  have  repeatedly  had  the  opportunity  to 
operate  for  lacerated  perineum  several  months  after  the  dehverj^  at  which 
the  accident  occurred,  all  my  operations  for  lacerated  cervix  were  done 
one  or  more  years  after  the  delivery,  when  the  usual  symjptoms  following 
that  lesion  had  had  time  to  develop. 

The  natural  application  of  this  experience  must  be  to  advise  that  phy- 
sicians make  it  their  invariable  rule  to  explore  the  condition  of  cervix,  va- 
gina, and  perineum  with  the  finger  immediately  after  delivery,  and  by  fin- 
ger and  speculum  (if  the  first  examination  revealed  more  or  less  injury) 
before  discharging  the  patient  from  their  obstetrical  care.  A  good  plan 
is  to  request  the  patient  to  call  at  the  office  on  one  of  her  first  walks  or 
drives  after  discharging  the  nurse,  by  which  time  sufficient  involution  will 
have  taken  place  to  enable  the  physician  to  determine  whether  the  lesion 
detected  immediately  after  labor  requires  operation,  and  if  so,  what  pre- 
paratory treatment  is  needed.  This  remark  applies  chiefly  to  laceration  of 
the  cervix,  the  immediate  union  of  which  by  sutures  is  scarcely  ever  prac- 
ticable under  the  conditions  as  to  light,  hemorrhage  from  the  uterine 
cavity,  exhaustion  of  patient,  edema  of  the  parts,  etc.,  present  after  nearly 
every  labor.     As  for  rupture  of  the  perineum,  I  need  hardly  say  that  if  of 


THE    BEST    TIxME    FOR    OPERATING.  413 

sufficient  extent  to  merit  the  name,  it  should  be  sewed  at  oxce.  If  jirimary 
union  does  not  take  place,  which  is  the  case  in  from  twenty-five  to  thirty- 
three  per  cent,  of  these  immediate  operations,  the  secondary  operation  will 
be  indicated  in  due  time.  If  this  rule  were  universally  observed  of  alwaya 
examining  a  woman  after  delivery  with  the  index-finger  in  the  rectum  and 
the  thumb  in  the  vagina,  and  estimating  by  the  tissue  to  be  felt  between 
the  two  whether  and  how  much  the  perineum  is  torn,  and  if  found  suffi- 
ciently injured,  of  sewing  it  at  once,  the  cases  of  secondary  operations 
coming  to  the  sjjecialist  would  be  diminished  at  least  one-half. 

The  operation  on  the  perineum  at  a  later  period — several  hours  to  two 
days — usually  fails,  although  a  Grerman  writer  has  recently  reported  sev- 
eral successes  as  late  as  thirty-six  hours  after  labor.  I  have  operated  but 
twice,  once  successfully  in  a  consultation  case  twelve  hours  after  labor,  and 
once,  also  in  a  consultation  case  of  complete  ruj)ture,  forty  hours  after  de- 
livery, inserting  eight  silver-wire  sutures  after  the  Emmet  method,  and 
failing  to  secure  union.  If  a  plastic  operation  has  failed,  it  is  usually  advis- 
able to  wait  until  the  wound  has  entirely  cicatrized  over  before  renewing 
the  attempt.  However,  in  one  instance  where  a  cervical  laceration  gaped 
completely  when  I  removed  the  stitches  one  week  after  the  operation, 
despite  the  utmost  care  observed  to  insure  union,  in  a  spirit  of  despera- 
tion I  scraped  the  granulating  surfaces  with  a  knife  and  immediately  re- 
united them  with  silver  sutures,  telling  the  patient  to  go  about  as  usual 
and  come  to  my  office  to  have  the  stitches  removed  in  ten  days.  She  did 
so,  and  I  found  the  wound  completely  healed  !  I  do  not  care  to  recom- 
mend this  practice,  however,  but  mention  the  case  merely  to  show  that 
such  a  tertiary  operation,  if  I  may  so  cal]  it,  may  prove  successful. 

These  two  lesions  of  lacerated  cervix  and  j)erineum,  being  j)i'oduced 
by  essentially  the  same  causes — rapid  labor,  large  child,  and  unyielding 
tissues  (primiparse) — very  frequently  occur  together,  and  may  both  need 
repair.  In  order  to  avoid  two  separate  o];)erations,  with  their  disagree- 
able companions  of  anesthesia  and  confinement  to  bed,  the  idea  naturally 
occurs  to  every  operator  to  do  them  both  at  one  sitting.  As  regards 
saving  of  time  the  object  is  undoubtedly  achieved  ;  but  the  length  of  the 
two  operations  combined,  the  possible  interference  with  the  union  of 
the  perineal  wound  by  the  not  unusual  muco-sanious  discharge  from  the 
cervix,  and  the  necessity  for  deferring  the  removal  of  the  cervical  sutui-es 
until  the  perineum  has  gained  sufficient  strength  to  bear  the  traction  of  a 
Sims  speculum — these  reasons  to  a  great  extent  outbalance  the  advan- 
tages of  the  double  operation.  In  the  few  cases  in  which  I  have  j^er- 
formed  it,  I  have  not  found  the  combination  as  successful  as  I  desired  in 
securing  clean  union  ;  perhaps  the  natural  haste  with  which  one  is  hable 
to  perform  operations  that  together  may  occupy  one  to  one  and  a  half 
hour,  the  joatient  being  under  full  anesthesia  all  this  time,  may  partly 
account  for  hurried  paring  and  suturing  and  imjierfect  result.  Still,  I  am 
inclined  to  try  the  combination  whenever  the  patient  appears  strong  and 
able  to  take  ether  well,  and  when  she  cannot  spare  the  time  or  positively 
objects  to  two  separate  operations.     The  cervix  may  then  be  sewed  with 


414  GYNECOLOGICAL    OPERATIONS. 

catgut,  whicli  need  never  be  removed,  and  thus  the  future  stretching  of  the 
fresh  perineum  for  the  removal  of  the  cervix  sutures  is  avoided.  In  such 
cases  the  cervix  can  usually  be  readily  drawn  to  the  vulva  and  the  knotting 
of  the  sutures  is  easy.  Silver  is,  however,  safer  than  catgut,  and  the  sutures 
need  not  be  removed  for  three  to  four  weeks,  when  the  new  peiineum  gen- 
rerally  bears  the  stretching  of  the  Sims  speculum.  In  several  cases  of 
prolapsus  uteri  with  rectocele  and  cystocele,  and  lacerated  cervdx,  I  have 
even,  for  like  reasons  of  economy  of  time,  combined  the  operation  on 
the  anterior  vaginal  wall  with  the  other  two,  and  have  had  very  good  re- 
sults. The  cystocele  operation  in  such  cases  was  a  peculiar  one  devised 
by  Stoltz,  of  Nancy,  and  is  knoAvn  as  the  running-bag  method,  which  I 
will  describe  hereafter. 

In  several  instances  I  have  also  combined  the  removal  of  hemorrhoids 
■with  trachelorraphy,  the  latter,  of  course,  being  first  performed.  The 
hemorrhoids  were  removed  with  the  Paquelin  thei'mo-cautery,  and  the  ex- 
ternal flaps  of  skin  trimmed  off  with  scissors,  and  the  wound  was  closed 
■with  fine  silk  sutures.  "When  the  stitches  were  removed  from  the  cervix 
on  the  tenth  day,  the  rectum  was  always  found  able  to  bear  the  backward 
pressure  of  the  s]Deculum. 

In  cases  of  hemorrhoids  and  lacerated  perineum,  it  is  advisable  to  re- 
move the  piles  first,  and  when  the  rectum  is  restored  to  health,  operate  on 
the  perineum.  The  tenesmus  and  edema  ■v\'hich  usually  follow  the  hem- 
orrhoid operation  would  be  very  hkely  to  interfere  with  the  undisturbed 
healing  of  the  perineal  wound.  Two  pathological  conditions  which  are 
very  frequently  associated  are  laceration  of  the  cervix  and  villous  degen- 
eration of  the  endometrium  ;  indeed  the  rent  retards  involution  of  the 
uterus  and  favors  hyperjDlasia  of  its  liaing  membrane.  Before  repairing 
the  rent  it  is  well  to  restore  the  endometrium  to  health  by  curetting  out  the 
vegetations  and  repeated  applications  of  tincture  of  iodine.  Some  operators 
curette  and  sew  the  tear  at  one  sitting.  But  I  think  the  chances  of  ulti- 
mate cure  of  the  hyperplasia  and  vegetations  is  rendered  doubtful  thereby  ; 
besides  the  bloody  oozing  following  curetting  for  several  days  might  inter- 
fere ■with  heahng  by  first  intention  of  the  cervical  wound.  I  greatly  prefer 
to  put  the  endometrium  in  as  healthy  a  condition  as  possible  before  oper- 
ating on  the  teai',  and  my  experience  has  led  me  to  feel  that  no  class  of 
gynecological  cases  offers  more  certainty  of  perfect  cure  than  these. 

As  to  when  ovarian  tumors  should  be  operated  on,  is  a  question  still 
somew^hat  under  discussion.  While  some  operators  still  adhere  to  the  old 
rule  of  Spencer  Wells  to  w^ait  until  the  system  begins  to  show-  the  effects 
of  the  disease,  until  cachexia  supervenes  and  the  peritoneum  has  become 
toughened  by  long  contact  with  the  gi'owth,  other  more  progressive  and 
bolder  surgeons  agree  with  Tait  in  operating  as  soon  as  the  tumor  has  at- 
tained a  noticeable  size  and  is  undoubtedly  growing.  It  seems  to  me 
that,  while  it  would  be  unjustifiable  to  remove  an  ovarian  tumor  which 
neither  by  its  size,  location,  nor  symptoms  seriously  distresses  the  patient 
or  impairs  her  health  or  activity,  it  must  be  equally  wrong  to  defer  the 
operation  \intil  the  patient's  constitution  begins  to  suffer.     The  stronger  a 


THE    BEST   TIME    FOR    OPERATING.  415 

woman  is  felie  better  she  will  be  likely  to  bear  a  severe  operation.  And  in 
our  present  days  of  Listerism  (I  mean  scrupulous  cleanliness  of  everybody 
and  everything  about  the  operator,  assistants  and  patient,  by  whatever  means 
secured)  the  old  bugbears  of  peritonitis  and  septicemia  are  by  no  means 
so  terrible  as  in  former  days.  While  no  rule  should  cover  every  case,  it 
seems  to  me  that  the  proper  time  to  operate  on  an  ovarian  tumor  (provided 
the  operator  has  the  choice  of  time)  is  when  the  tumor  is  evidently  grow- 
ing, when  sharp  abdominal  pains  lead  to  the  suspicion  of  localized  peri- 
tonitis and  adhesions,  and  when  the  tumor  by  pressure,  pain,  or  other- 
wise, seriously  distresses  the  patient.  The  moral  indication  of  mental 
worry  through  knowledge  of  the  presence  of  the  tumor  and  fear  of  its 
ultimate  consequences  may  occasionally  require  consideration. 

When  to  remove  the  "normal" — that  is,  not  enlarged — ovaries  and  Fal- 
lopian tubes,  for  local  and  general  symptoms  apparently  depending  on  dis- 
ease of  those  organs,  is  a  subject  at  present  agitating  the  professional 
mind.  Battey's  operation,  the  removal  of  the  ovaries  alone,  is  called  for 
whenever  constantly  recurrent  menstrual  pain,  of  so  severe  a  character 
as  to  render  the  life  of  the  patient  unendurable  and  practically  useless, 
continues  for  years,  resists  all  local  and  general  medication,  and  ulti- 
mately bids  fair  to  unsettle  her  reason  and  permanently  shatter  her  nervous 
system.  Further,  when  a  fibroid  of  the  uterus,  either  by  its  rapid  gi'owth, 
large  size,  or  the  hemorrhage  it  produces,  calls  for  operative  interference, 
and  is  not  removable,  the  attempt  should  be  made  to  check  its  gi'owth  by 
removing  the  ovaries  and  thus  anticipating  the  menopause. 

The  ovaries  have  also  been  successfully  removed  by  Hegar  and  others 
in  cases  of  so-called  recurrent  peritonitis  and  cellulitis,  when  every  men- 
strual period  ushered  in  a  more  or  less  severe  attack  of  pelvic  pain  attended 
with  febrile  reaction.  It  is  for  this  class  of  cases,  and  for  those  cases  of 
long-standing  cellulitis  of  the  broad  ligaments  (as  we  have  been  accustomed 
to  call  them),  where  the  lateral  portions  of  the  pelvic  cavity  feel  puify, 
doughy,  more  or  less  infiltrated,  that  Lawson  Tait  has  recently  advised  and 
successfully  practised  in  numerous  cases  the  removal  of  not  only  the  ovaries 
but  also  the  tubes.  In  chronic  inflammation  and  dilatation  of  the  latter, 
chiefly,  he  sees  the  cause  of  the  suffering  and  joersistence  against  all  reme- 
dies so  characteristic  of  these  cases.  It  is  the  dilated  tube,  filled  •u'ith  pus, 
which  we  feel  at  either  side  of  the  uterus  and  which  has  so  long  been  mis- 
taken for  a  plastic  exudation  in  the  cellular  tissue  of  the  broad  ligament. 
Tait's  specimens  (over  sixty)  certainly  confirm  his  diagnosis,  and  his  mar- 
vellous results  (only  two  deaths,  and  restoration  to  health  in  all  the  others) 
speak  not  only  for  his  operative  dexterity,  but  also  for  the  coiTectness  of 
his  statements.  When  we  can  point  to  similar  results  and  a  like  low  mor- 
tality from  this  operation,  we  can  afford  to  risk  a  mistake  in  diagnosis  oc- 
casionally. At  the  present  time,  what  we  need  before  entering  on  a  cam- 
paign of  oophoro-salpingectomy  is  more  acciu'ate  means  than  we  now  have 
of  diagnosing  the  enlargement  of  the  tube.  So  far  we  are  hardly  prepared 
in  this  country  to  act  on  Tait's  rule,  that  cases  of  so-called  chronic  cellulitis 
of  the  broad  ligament  which  resist  the  usual  treatment  over  six  months, 


416  GYNAECOLOGICAL    OPERATIONS. 

are  instances  of  salpingitis  and  pyosalpinx,  and  call  for  the  removal  of  the 
offending  organ. 

It  should  be  stated  that  Tait  advises  the  removal  of  the  tubes  together 
with  the  ovary  in  eveiy  case  of  Battey's  operation,  as  he  thinks  the  opera- 
ation  imperfect  if  the  tubes  are  allowed  to  remain. 

I  need  hardly  say  that  the  general  health  of  the  patient  should  be  such 
that  she  will  not  only  sui-vive  the  operation,  but  stand  a  fair  chance  of  re- 
covery from  the  various  intercurrent  dangers  which  may  beset  her  after- 
ward. It  is  hardly  worth  while  to  operate  on  a  patient  whose  recuperative 
powers  are  so  feeble  that  she  can  scarcely  rally  from  the  operation  or  supply 
plastic  material  sufficient  to  close  the  fresh  wound.  This  remark  applies 
equally  to  the  lesser  plastic  operations  on  the  female  genital  organs,  as  to 
the  capital  operations  of  laparotomy,  etc.  A  secondary  operation  for  lacer- 
ated cerdx  or  perineum  gives  a  much  better  result  if  the  patient  is  strong 
and  well  nourished,  than  if  she  is  anemic,  and  physically  and  mentally 
debihtated.  The  indication,  therefore,  is  to  "build  up  "  all  such  patients 
before  operating. 

The  choice  of  the  place  to  operate,  whether  in  a  hospital  or  a  private  house, 
will  come  up  for  decision  only  in  cases  of  private  patients  whose  means  en- 
able them  to  secure  such  attendance  and  comforts  at  their  homes  as  the 
operation  demands.  It  goes  almost  without  saying  that  a  patient  who  can 
afford  neither  a  nurse,  nor  suitable  food,  nor  the  quiet  necessary  to  recovery 
at  her  home,  m  ust  go  to  a  hospital.  Patients,  even,  who  can  have  fail'  at- 
tendance at  home,  but  whose  quarters  are  cramjDed,  or  who  are  liable  to  be 
troubled  with  household  and  family  matters,  had  much  better,  especially  if 
the  operation  is  a  serious  one,  take  a  private  room  in  a  hospital.  For  minor 
operations,  such  as  trachelorrhaphy  and  perineorrhaphy,  chiefly  the  former, 
where  but  httle  trained  nursing  is  needed,  even  moderate  conveniences 
at  home  will  suffice,  and  such  patients  certainly  need  not  leave  their  families 
to  be  confined  in  a  hospital.  To  insist  upon  their  doing  so,  when  their 
means  allow  them  to  be  well  taken  care  of  at  home,  is  simply  arbitraiy. 
I  have  done  numerous  operations  of  this  kind  at  private  houses,  and  in  my 
earlier  years  not  always  in  brown-stone  fronts,  and  have  seldom  failed  to 
get  a  good  result.  In  fact,  my  first  failure  in  over  sixty  perineoiThaphies 
was  in  the  hospital,  and  many  of  these  operations  had  been  done  in  tene- 
ment-houses, with  often  no  nurse  but  some  friend  of  the  patient. 

As  for  capital  operations,  like  laparotomies,  if  the  patient  can  afford  all 
the  medical  attendance,  nursing,  and  conveniences  which  such  cases  require 
at  her  home,  I  unhesitatingly  prefer  it  to  even  the  private  rooms  of  a 
general  hospital.  I  cannot  divest  myself  of  the  idea  that  there  is  less  dan- 
ger of  septic  infection  in  an  airy,  clean  room  of  moderate  size  in  a  private 
bouse,  than  in  a  hospital  with  its  thousand  and  one  sources  of  contamina- 
tion, no  matter  how  well  it  be  organized. 

Still,  I  also  believe  that  scrupulous  cleanliness  and  thorough  disinfection 
will  render  a  hospital— not  only  the  operating-room  and  private  rooms,  but 
also  the  general  surgical  ward— as  absolutely  pure  as  a  private  house.  In 
proof  of  this  assertion,  I  have  during  the  past  year  put  two  ooiDhorectomies, 


PREPARATORY  TREATMENT.  417 

one  ovariotomy,  one  colpo-liysterectomy  for  cancer,  one  large  cyst  of  tlie 
broad  ligament  where  the  sac  was  stitched  to  the  abdominal  wound,  and 
one  enucleation  of  a  large  cervical  fibroid  obstructing  labor,  into  my  gen- 
eral uterine  ward  at  Mount  Sinai  Hospital,  where  twenty  cervix,  perineum, 
fistula,  and  other  cases,  operative  and  not,  were  lying — and  all  recovered 
with  scarcely  a  rise  of  temperature. 

The  better  the  hygienic  conditions  and  surroundings  of  a  patient  after 
operation,  the  more  favorable,  of  course,  ceteiHs  paribus,  are  her  chances  of 
recovery.  The  most  favorable  conditions  for  operation  are,  therefore,  such 
as  are  afforded  by  the  pavilion  system  of  hosj)itals,  where  each  patient  oc- 
cupies a  separate  room,  which  is  thoroughly  disinfected  before  being  used 
again.  Such  a  hospital  surpasses  even  the  best  private  dwelling,  since 
physicians  and  competent  nurses,  with  all  conveniences,  are  constantly  at  a 
moment's  notice. 

2.  Peepahatory  Teeatment. 

The  general  treatment  to  prepare  a  patient  for  an  oj)eration  consists 
chiefly  in  tonics — medicinal  and  hygienic — until  her  system  is  brought  to 
a  good  condition  for  the  reparative  processes  which  surgical  interfex'ence 
usually  calls  for.  Quinine,  iron,  strychnine,  the  phosphates  and  hypo- 
phosphites,  cod-liver  oil ;  bathing,  massage,  general  faradization  ;  exercise, 
air,  noru'ishiug  diet  (stronger  stimulants  only  in  moderate  quantities, 
wines  and  malt  liquors  in  fair  quantity) ;  cheerful  surroundings,  sunlight 
— all  these  agents  will  tend  to  invigorate  the  system  and  render  it  more 
competent  not  only  to  stand  the  shock  of  the  operation,  but  also  to  repair 
the  necessar}'  injury  inflicted.  In  the  major  operations,  such  as  laj^arot- 
omy,  this  preparatory  "  building  up "  is  of  supreme  imj)ortance,  as  the 
shock  of  these  operations  is  often  so  great  that  a  debilitated  system  is  un- 
able to  rally  from  it.  As  a  rule,  the  better  the  physique  and  morale  of 
the  patient,  the  better  her  chances  for  recovery  from  any  operation.  It 
is  not  the  danger  of  inflammation  which  we  fear  now ;  oiu-  modern  anti- 
phlogistic measures  enable  us  to  deal  with  this  ancient  bugbear  with  tol- 
erable certainty ;  nor  do  we  fear  the  invasion  of  the  mysterious  bacteria 
and  bacilli,  the  carriers  of  septic  infection,  for  Listerism  (that  is,  absolute 
cleanliness)  will  keep  them  at  a  distance  or  render  them  innocuous  in  a 
large  proportion  of  cases.  What  we  need  chiefly  is  a  strong,  rigorous  con- 
stitution to  resist  the  dangers  of  the  operation  itself,  and  the  subsequent 
more  or  less  tedious  recovery.  "We  want  tissues  which  will  unite  b}'  first 
intention  ;  and  these  we  can  get,  whenever  feasible,  by  a  previous  course 
of  tonics.  Only  in  urgent  cases  would  it  be  safe  to  operate  on  a  debilitated 
patient  and  to  take  our  chances  of  union. 

A  constitutional  taint,  such  as,  above  all,  syphilis,  then  purpiu-a,  gout,  or 
rheumatism,  if  in  the  active  stage,  will  counter-indicate  an  operation. 
But  if  latent,  not  manifesting  acute  or  local  symptoms,  a  plastic  operation 
will  often  succeed.  Thus,  if  the  vulva  was  covered  with  mucous  patches, 
which  have  completely  disappeared  under  specific  treatment,  a  peiineor- 
27 


418  GYNECOLOGICAL    OPERATIONS. 

rhaphy  may  be  perfectly  successful,  even  though  there  be  latent  evidences 
of  syphilis  in  other  parts  of  the  body.  But  it  is  weU  to  continue  the  con- 
stitutional ti-eatment  for  some  time  after  the  operation.  That  attention 
should  be  paid  to  regulating  the  functions  of  the  bowels  and  kidneys  need 
scarcely  be  emphasized.  That  of  the  skin  has  abeady  been  referred  to  in 
speaking  of  the  necessity  of  bathing  and  massage. 

Local  preparatory  treatment  comprises  such  measures  as  tend  to  put 
the  parts  to  be  operated  on  in  as  good  a  condition  for  healing  as  possible. 
Thus,  a  lacerated  cervix  is  treated  by  tincture  of  iodine,  tannin  and  glycer- 
ine, and  iodoform,  until  the  frequently  existing  hyperemia  or  hypersecre- 
tion (endotrachelian  catarrh)  is  removed;  a  redundant  (submvoluted) 
vagma  (rectocele  or  cystocele)  is  reduced  in  size  as  much  as  feasible  by 
astringent  tampons;  a  lacerated  perineum  is  glazed  over  by  astringent 
injections  and  dusting  with  iodoform  ;  a  vesico-vaginal  fistula  is  rendered 
accessible  and  its  edges  are  softened  by  hot-water  injections  and  column- 
ing  the  vagina  with  cotton. 

This  treatment  may  extend  over  several  months  ;  but  the  time  thus  oc- 
cupied is  not  wasted,  since  the  better  the  reparative  power  of  the  injured 
parts,  the  better  the  result  of  the  operation.  Indeed,  many  cases  of 
trachelorraphy  or  fistula  operation  would  be  utterly  hopeless  unless  the 
parts  were  first  put  in  good  condition  for  healing. 

It  must  be  remembered  that  to  secure  imion  by  first  intention  the  tissues 
should  be  neither  too  hyperemic,  nor  too  anemic,  and  that,  above  aU,  cica- 
tricial tissue  manifests  but  little  tendency  to  primary  union.  Therefore, 
such  cicatricial  tissue  as  lies  in  the  way  and  cannot  be  dispersed  before- 
hand, must  be  removed  by  the  knife  or  scissors  at  the  operation. 

The  after-treatment  consists  mainly  in  a  continuance  or  renewal  of  the 
preparatory  tonic  treatment,  in  tejDid  antiseptic,  perhaps  astringent  injec- 
tions ;  in  tannin  tampons  and  iodine  applications  to  the  cervix  ;  in  vaseline 
inunctions  to  the  perineum  ;  in  abdominal  supporters  after  laparotomy, 
and  various  other  measures  needed  to  complete  the  restoration  of  the  parts, 
which  wiU  be  discussed  in  their  respective  places. 

The  diet  should  depend  on  the  ability  of  the  patient  to  take  much  or 
Httle,  and  on  the  necessities  of  the  case.  For  the  first  few  days  it  should 
be  fluid,  but  nutritious,  mainly  milk  ;  in  laparotomies,  it  is  seldom  any- 
thing but  fluid  for  the  first  week  or  more,  and  nothing  bu.t  ci'acked  ice  for 
the  first  twenty-four  houi's. 

Stimulants  should  be  given  entirely  in  proportion  to  their  need.  So 
long  as  the  nausea  of  the  anesthetic  lasts,  nothing  but  cracked  ice,  perhaps 
a  lemon  to  suck,  should  be  given.  Plain  water  to  drink,  also  carbonic 
acid  or  Vichy  water  may  be  allowed  cold  in  moderate  quantity.  Bedsores 
should  be  prevented  by  occasional  change  of  position,  by  alcohol  rubbings, 
and  by  air-cushions.  The  temperature  of  the  room  should  not  be  above 
70°  F. 


THE    SUTUEE.  419 


3.  The  Sutuee. 

The  principles  governing  the  union  by  suture  of  wounds  of  the  female 
genital  organs  are  essentially  the  same  as  those  guiding  other  surgical 
operations.  But  the  instruments  and  material  for  sutures,  and  the  rules 
for  suturing  gynecological  wounds,  are  peculiar  to  that  class  of  oper- 
ations, and  a  description  of  these  will,  I  think,  prove  instructive  and 
useful. 

Operations  on  the  female  genital  organs,  particularly  those  for  repair 
of  injuries  to  the  vulva,  vagina,  and  cervix,  are  chiefly  of  a  plastic  charac- 
ter, in  the  course  of  which  it  is  necessary  first  to  remove  excessive  or 
pathological  tissue,  and  to  prepare  a  fresh  raw  surface  of  varying  shape  and 
dimensions,  and  secondly,  so  to  adapt  the  edges  of  this  sui'face  as  to  se- 
cure rapid  and  complete  union  of  the  opposing  surfaces.  To  attain  this 
end,  two  cardinal  principles  must  be  observed  :  1.  Thorough,  careful,  and 
regular  paring,  and  2.  Exact  and  complete  approximation  of  the  surfaces 
to  be  united.  These  surfaces  may  be  considerable  in  extent,  as  in  opera- 
tions for  lacerated  perineum,  prolapsus  uteri  et  vaginae,  or  the  tissues 
may  be  dense  and  difficult  of  approximation,  as  in  trachelorrhaphy  and 
vesico-vaginal  fisttdse,  or  they  may  be  unusually  soft  and  vascular,  and 
both  of  the  above-mentioned  cardinal  I'ules  may  be  difficult  of  execution. 
Thus,  in  colpo-perineorrhaphy  it  may  not  be  easy  to  remove  every  strijD  of 
mucous  membrane,  and  small  patches  of  the  latter  may  accidentally  be 
left  and  interfere  with  perfect  union,  or  the  length  and  circuitous  course 
of  the  sutures  may  facilitate  the  formation  of  small  pockets  in  the  wound 
in  which  secretion  or  pus  may  accumulate.  Again,  in  trachelorrhaphy,  the 
density  of  the  deeper  tissue  of  the  cervix  may  make  it  difficult  to  prepare 
a  sufficiently  large  raw  surface,  or  to  approximate  the  everted  lips  with  the 
sutures ;  or,  in  the  latter  case,  as  well  as  when  the  tissues  are  too  succu- 
lent, the  stitches  may  sink  too  deep  and  cut  their  way  out  before  perfect 
union  has  taken  place.  Or  they  may  obstruct  circulation  and  cause 
sloughing  or  suppuration  in  the  wound. 

Ceteris  paribus,  the  larger  the  raw  surfaces  the  better  the  chance  of 
their  uniting.  Hence,  where  there  is  tissue  to  spare  it  is  always  safe  to 
make  the  denudation  as  ample  as  is  consistent  with  the  normal  shape  and 
size  of  the  part  to  be  restored. 

It  is  also  desirable  to  have  the  wound  as  smooth  as  possible.  Eagged 
shreds  of  raw  tissue  should  be  trimmed  off,  the  edges  of  the  wound 
smoothed  with  scissors,  and  all  superfliious  tissue  removed.  Coagula 
should  be  wiped  away  and  the  wound  dried  as  much  as  possible  by  car- 
bolized  sponges  before  approximating  its  surfaces  and  securing  the  sutures. 
It  is  not  necessary  that  bleeding  should  be  arrested  before  closing  the 
wound  ;  indeed,  in  many  operations  on  the  cervix,  vagina,  and  ijeriueum, 
the  raw  surface  oozes  until  the  sutures  compress  the  bleeding  vessels. 
But  all  loose  blood  should  be  sponged  away  immediately  before  the  wound 
is  closed.     In  laparotomy,  of  course,  all  intraperitoneal  oozing  should  be 


420 


GYNECOLOGICAL    OPERATIONS. 


arrested  before  the  abdominal  wound  is  closed  ;  at  least  this  is  the  rule  in 
this  country,  although  I  am  informed  that  Tait  is  not  so  particular  in 
this  respect  as  one  would  think  advisable  ;  still,  his  unequalled  results  seem 
to  prove  that,  in  England  at  least,  a  httle  bloody  serum  in  the  peritoneal 
cavity  does  not  interfere  with  recoveiy. 

For  arresting  hemorrhage  I  have  always  preferred  ice-water  to  hot 
water,  because  I  am  always  sure  of  having  the  ice-water  cold  enough,  but 
cannot  always  get  or  keep  the  hot  water  hot  enough.  Still,  occasionally  I 
found  very  hot  sponges  effectual  in  temporarily  aiTesting  capillary  oozing. 
The  effect,  however,  was  always  temporary,  and  this  has  been  my  experi- 
ence with  hot  water  as  a  hemostatic  throughout.  It  arrests  the  bleeding, 
but  not  permanently  as  cold  does.  In  laparotomies,  to  be  sure,  I  use  hot 
sponges  for  the  peritoneal  toilet.  The  German  method  of  irrigating  the 
wound  (as  in  trachelorrhaphy  or  perineorrhaphy)  with  a  hot  or  cold  anti- 
sei^tic  solution,  instead  of  sponging,  has  not  become  popular  with  us,  nor 
do  I  think  it  so  convenient  as  the  old  method  of  sponging. 

Spurting  arteries,  which  are  sometimes  met  with  in  cervix,  fistula,  and 
perineum  ojDerations,  should  be  twisted  or  compressed  by  artery  forceps 
on  general  principles,  or  perhaps  ligated  with  silk  or  catgut. 

The  needles  adapted  to  gynecological  ojDerations  differ  with  the  particu- 
lar operation.     For  the  operation  of  laceration  of  the  cervix  uteri,  short. 


Fig.  218.— 1,  Sims'  Cervix  Needle.  2,  Em- 
met's Fistula  Needle.  3.  Emmefs  Cervix 
Needle.  4,  Straight  Terineum  Needle.  5, 
Schnetter's  Cervix  Needle.  (This  last  needle  is 
figured  nearly  double  the  size  used)  (P.  F.  II. J. 


Fig.  219.— 1,  Simon's  Vesicovaginal  Fistula 
Needle.  2,  Large  Needle  for  Primarv  Peri- 
neum Operations  and  Abdominal  Wall  in 
Ovariotomy  (P.  F.  M.). 


stout,  round,  slightly  cuiwed  needles  with  beveUed,  or  cutting  point,  are 
used  ;  for  the  operation  of  lacerated  peiineum,  straight  needles  of  different 
length,  similar  to  ordinary  darning-needles  ;  for  plastic  operations  on  the 
vagina  (rectocele,  cystocele,  prolapsus  uteri)  short,  round,  sUghtly  curved, 
or  ordmary  flat,  sUghtly  cui'ved,  surgical  needles,  have  been  found  the  most 
serviceable.  For  vesico-vaginal  fistula  operations,  short,  round,  shai-p- 
pomted  needles,  of  different  curves,  from  a  shght  to  almost  a  semi-circular 
curve  answer  best.  For  laparotomies,  straight  lance-pointed  needles,  for 
pedicle  and  adhesions,  or  if  both  ends  of  the  suture  are  threaded,  for  the 
abdominal  wound,  passed  fi-om  within  outward;  or  long,  strong,  shai^ly 
curved  needles,  with  sharp  point  and  cutting  edges  may  be  used  for  the 
abdomuial  suture,  being  passed  from  without  inward  on  one  side,  and  from 
withm  outward  on  the  other  side.  These  same  needles,  last  mentioned, 
txe,  in  my  opinion,  the  best  for  primary  union  of  a  perineal  laceration. 


THE    SUTURE.  421 

While  round  needles  do  not  pierce  the  tissues  as  well,  they  are  less 
likely  to  cut  vessels  and  cause  hemorrhage.  Needles  with  lance  or  spear 
points  may  accidentally  strike  a  large  vein  or  even  an  artery,  and  produce 
considerable  oozing.  Care  should  therefore  be  taken  always  to  avoid  visi- 
ble or  pulsating  vessels  in  passing  a  suture. 

Needles  immovably  attached  to  a  handle  have  been  used  for  perineor- 
rhaphy (Peaslee's  needle,  Fig.  220),  and  for  passing  the  ligatures  through 
ovarian  pedicles  and  adhesions.  There  are  several  curves  of  this  needle 
which  can  be  screwed  on  the  same  handle.  The  eye  is  near  the  point,  and 
a  loop  of  silk  is  passed  through  it  and  knotted  ;  when  the  needle  emerges 
from  the  tissue,  the  loop  of  silk  is  drawn  out  with  a  tenaculum,  the  silk 
ligature  or  wire  suture  is  hooked  in,  and  the  needle  is  drawn  back  as  it 
entered  with  the  suture.  This  form  of  needle  is  still  used  in  laparotomy, 
for  the  pedicle  and  the  abdominal  wound,  otherwise  it  has  been  super- 
seded by  the  movable  needles  mentioned. 


Fig.  220. — Peaslee's  Needle  for  Perineorrhaphy,  etc. 

The  material  used  for  sutures  is  either  silk,  catgut,  or  silver  wire. 
Substitutes  for  these  have  been  introduced  from  time  to  time,  such  as 
whale-sinew,  silkworm  gut,  plated  iron  wire,  etc.,  but  have  not  stood  the 
test  of  experience.  For  all  operations  where  it  is  not  desired  to  leave 
the  suture  in  the  tissue  longer  than  four  or  five  days  silk  doubtless  sur- 
passes every  other  material.  And  if  properly  asej)ticized  it  can  even  be 
retained  a  week,  or  longer,  without  exciting  suppuration.  Witness  the 
ligatures  on  adhesions  and  pedicle  in  ovariotomies,  which  are  dropped  and 
never  heard  from  again.  To  render  silk  properly  aseptic,  it  may  either 
be  boiled  for  an  hour  in  a  ten  per  cent,  solution  of  carbolic  acid,  then 
washed  in  a  five  per  cent,  solution,  and  kept  in  a  three  per  cent,  solution  in 
a  well-stoppered  bottle  until  used  (as  was  hitherto  the  practice) ;  or  accord- 
ing to  the  new  custom  it  may  be  boiled  in  a  one  to  one  thousand  solution 
of  corrosive  sublimate  for  half  an  hour,  then  washed  in  a  one  to  two  thou- 
sand, and  preserved  in  the  same  solution  until  used.  If  kej)t  veiy  long, 
however — that  is,  several  weeks  or  more — it  is  liable  to  get  rotten  and  break 
easily.  It  is  well,  therefore,  to  prepare  only  a  little  at  a  time,  or,  better 
still,  for  each  operation.  The  latter  should  certainly  be  the  rule  for  capital 
operations,  like  laparotomy,  where  it  is  of  prime  importance  that  ligatiu'es 
do  not  break. 

The  best  is  the  braided  silk  or  cord  of  Archibald  Turner  k  Co.,  which 
comes  in  four  graded  sizes,  of  which  the  finest  is  for  small  artery  ligatiu'es 
and  fine  sutures  ;  the  second  size  for  larger  ligatures  and  as  loops  for  wire 
sutures  ;  the  thii-d  size  for  adhesions,  sutures  of  thick  tissues  (abdominal 
wall,  perineum,  cervix,  fistula),  and  as  guide  for  large  \d\'e  sutures  (in 
perineorrhaphy)  ;  and  the  fourth,  or  largest  size,  single  or  double,  for  pedicle 


423  GYNECOLOGICAL    OPERATIONS. 

iu  ovariotomy,  Taifs  and  Battey's  operations,  etc.  It  is  always  well  to  have 
some  of  each  of  these  sizes  prepared  for  each  operation,  except  perhaps 
trachelorrhaphy,  where  sizes  Nos.  2  and  3  will  suffice.  In  laparotomy  I 
never  use  any  ligature  or  suture  but  this  silk.  A  caution,  iu  tying  this 
braided  silk,  may  not  be  amiss,  viz.,  when  a  very  tight  knot  is  to  be  tied, 
as,  for  instance,  when  ligating  the  pedicle  of  an  ovarian  tumor  or  a  thick 
adhesion  which  may  shrink  and  loosen  the  hgature,  do  not  cross  the  silk 
twice  iu  the  first  knot,  as  is  usually  done  to  prevent  its  slipping,  but  have  it 
held  by  forceps  until  the  second  and  final  knot  is  well  tightened.  I  have 
repeatedly  noticed  that  doubling  the  first  loop  causes  the  braided  silk  to 
snap  when  the  second  knot  is  tightly  drawn.  This  is  not  the  case  with  or- 
dinaiw  twisted  silk.  Further,  the  knot  of  braided  silk  occasionally  shps, 
as  I  have  noticed  in  closing  the  abdominal  wound  after  laparotomy,  and  it 
is  well  then  to  tie  a  thu-d  knot  for  security. 

Catgut  comes  in  thi-ee  sizes,  of  which  No.  1  is  used  for  fine  artery  liga- 
tures and  sutui-es,  Nos.  2  and  3  for  strong  ligatures  and  sutures.  Its  chief 
advantage  is  its  ready  absorption  when  it  is  desired  to  drop  it  permanently, 
as  for  adhesions  and  vessels  in  laparotomy,  and  in  closing  wounds,  from 
which  it  would  be  difficult  to  remove  it  later  on,  as  in  lacerated  cervix  and 
operations  on  the  vaginal  wall,  together  with  perineorraphy.  In  the  latter 
oiiex-ation  (colporrhaphy),  particularly,  I  have  found  it  useful.  But  its  very 
advantage  of  readiness  of  absorption  may  itself  prove  a  disadvantage,  iu 
that  the  hgatui-e  or  suture  becomes  absorbed  too  soon  (its  usual  time 
is  four  to  six  days)  before  thorough  thrombosis  or  firm  union  has  taken 
place,  and  secondary  hemorrhage  or  reopening  of  the  wound  may  occur. 
I  confess  that  I  do  not  trust  catgut  where  I  am  particularly  anxious  to 
avoid  either  of  these  occuiTences,  and  have  felt  easy  in  using  it  only  in 
trachelorrhaphy  and  colporrhaphy  (combined  with  perineorrhaphy),  occa- 
sionally to  ligate  an  artery  on  the  surface  of  a  perineorrhaj)hy.  In  la- 
parotomies I  have  felt  much  safer  with  silk,  the  presence  of  which  very 
rarely  causes  subsequent  trouble.  Catgut  is  bought  preserved  in  oil,  and 
is  disinfected  by  keeping  it  iu  a  five  per  cent,  solution  of  carbolated  oil. 
It  is  threaded  and  tied  precisely  like  silk. 

Silver  loire,  as  a  sutui-e,  was  first  popularized  by  J.  Marion  Sims,  to  whom 
also  we  owe  the  various  instruments  necessary  to  its  proper  adjustment. 
Its  great  advantage  over  silk  was  that  it  could  be  left  in  the  tissues  for  an 
indefinite  length  of  time  without  absorbing  fluids,  becoming  offensive,  ex- 
citing suppuration,  or  cutting  through,  featm-es  which  rendered  it  particu- 
larly available  for  plastic  operations.  It  was  these  qualities  Avhich  enabled 
Sims  to  cure  his  first  case  of  vesico-vaginal  fistula.  In  justice  it  must  be 
said,  however,  that  Simon,  of  Heidelberg,  cured  equally  large  fistulee  with 
raw  silk  sutures,  which  were  allowed  to  remain  a  week,  and  did  not  cut 
through.  But  silver  wii-e  has  become  so  popular  in  this  country  that  it  is 
the  suture  universaUy  employed  for  all  j^lastic  operations  on  the  female 
genitals,  and  I  must  confess  that,  for  neatness,  cleanliness,  and  ease  of 
handling  in  cavities,  I  certainly  prefer  it  to  silk. 

Silver  wire  comes  iu  different  thicknesses,  and  is  usually  sold  by  weight. 


TELE    SUTURE. 


423 


The  thickest  size  used  in  gynecological  operations  is  No.  25  ;  the  thinnest, 
for  superficial  sutures,  No.  33.  The  usual  size  for  tracheloiThaphy  is  No. 
27  ;  for  perineorrhaphy,  No.  26  ;  for  fistulse,  No.  28,  Special  care  should  be 
taken  to  have  it  perfectly  pure,  and  so  malleable  that  it  will  not  .snap  Avhen 
tightly  twisted. 

AYire  sutures  should  be  from  ten  to  twelve  inches  long,  in  order  to 
allow  for  loose  twisting  and  handhng  before  permanent  twisting.  The  wire 
can  be  kept  unbent  and  smooth  in  a 
piece  of  black  rubber  tubing  slightly 
shorter  than  the  sutures.  Before 
using,  they  should  be  polished  off 
and  disinfected,  as  they  become 
tarnished. 

As  a  rule,  wire  is  not  used  direct- 
ly in  the  needle,  but  indirectly,  being 
hooked  to  a  loop  of  stout  silk  with 
which  the  needle  is  threaded.  It  is 
a  matter  of  considerable  importance 
that  the  needle  be  so  threaded  that  no  knot  or  unevenness  at  the  eye  in- 
terferes with  its  easy  passage  through  the  tissues.  The  method  in  vogue 
at  the  Woman's  Hospital  for  many  years,  in  threading  all  needles  for  wire, 
whether  for  cervix,  perineum,  or  other  operations,  is  the  following  :  Both 
ends  of  the  silk  are  passed  thi'ough  the  eye  (Fig.  221),  and  then  tied 


Fig.  221.— Double  Threading  of  Needle  for  Wire. 
First  step  (P.  F.  JI.). 


Fig.  222.— Double  Threading  of  Needle  for  Wire.    Second  step  (P.  F.  M.). 

tightly  in  a  single  knot,  which  is  laid  smoothly  in  a  Hne  with  the  shaft  of 
the  needle  (Fig.  222).  If  this  single  knot  is  tightly  drawn,  and  the  eye 
part  of  the  needle  is  grasped  in  the  needle-holder,  the  knot  will  rarely  slip, 
especially  when  the  silk  becomes  moist.  Another  method,  which  is  prac- 
ticable only  when  braided  silk  is  used,  has  been  devised  by  my  assistant, 


Fig.  22.3.— Wells'  Method  of  Threading  Needle  for  Wire  (P.  P.  M.). 

Dr.  B.  H.  Wells,  and  consists  in  transfixing  both  strands  of  silk  after  they 
have  been  passed  through  the  eye  with  the  needle,  and  then  drawing  the 
loop  thus  made  tightly  down  over  the  head  of  the  needle  (Fig.  223). 


424 


GYNECOLOGICAL    OPERATIONS. 


A  very  easy  and  reliable  method  of  threading  a  needle,  chiefly  for 
perineorrhaphy,  where  there  is  less  danger  of  confusing  the  threads  than  in 
the  vagina,  is  to  pass  the  two  threads  in  opposite  directions,  and  then 


Fig.  224.— Chamberlain's  Method  of  Threading  Needle  for  Wire  (P.  F.  M.). 

draw  them  through  two  to  three  inches,  and  leave  the  ends  entirely  untied  ; 
the  free  ends  of  the  silk  are  then  almost  as  long  as  the  loop,  and  are  little 
liable  to  slip  out  when  the  needle  is  drawn  out  of  the  flesh.  The  entire 
absence  of  a  knot  or  inequahty  in  the  loop  is  the  great  advantage  of  this 
method,  for  even  the  flat  single  knots  described  may  catch  in  the  depth 
of  a  long  wound  or  in  a  tough  cervix,  and,  particularly  in  the  recto-vaginal 
septum,  will  enlarge  the  width  of  the  suture-channel. 


^S^ 


Fig.  925.— Wire  Hooked  into  Silk  Loop  and  Bent  Down  (P.  F,  M.). 

It  is,  of  course,  understood  that  the  silk  is  intended  merely  as  a  guide 
to  the  silver  wire  which  is  hooked  into  the  loop  of  silk  and  smoothly 
squeezed  down  so  as  not  to  project  (Fig.  225).  The  wire  is  bent  at  a 
right  angle  over  the  edge  of  a  knife  or  scissors  ;  if  bent  in  a  curve,  it  is 
sure  to  catch  when  being  drawn  through  the  tissues,  and  may  then  become 
detached,  which  requires  the  reinsertion  of  that  suture.  To  avoid  this,  it 
is  well  to  bend  the  wke  down  smoothly  with  the  needle-forceps. 


Fig.  2i6.— Emmef  8  Needle-holder. 


The  wire  hook  should  not  be  twisted,  merely  bent ;  if  twisted,  the  oper- 
ator  IS  delayed  when  detaching  the  wire  after  he  has  passed  the  suture. 
J^or  the  pui'pose  of  introducing  the  sutures,  needle-holders  of  different 


THE    SUTURE. 


425 


pattern,  have  been  constructed.  I  prefer  that  known  as  Emmet's,  but  that 
of  Sims,  and  that  known  as  the  "Russian  needle-holder,"  besides  others, 
have  each  their  partisans.  The  difficulty  with  almost  all  needle-holders  is 
that  they  either  do  not  grip  the  needle  tightly  enough,  and  it  slips  on 
being  forced  through  the  tissues,  or  that  they  grip  too  tightly  and  the  eye 
of  the  needle  is  broken  off.     To  obviate  either  of  these  occurrences,  one 


Fig.  227.— Sims'  Shield. 


jaw  of  the  catch  of  the  holder  is  lined  with  lead  or  copper,  and  the  other 
is  crossed  by  intersecting  grooves,  into  which  the  needle  is  to  fit.  In  spite 
of  this,  nothing  occurs  more  frequently  than  to  snap  off  the  head  of  the 
needle  by  a  sudden  twist  of  the  wrist. 

It  takes  some  experience  to  manipulate  these  holders  well  in  the  depths 
of  the  vagina,  as  in  a  difficult  trachelorrhaphy. 

It  is  generally  a  good  plan  to  fasten  the  wire  in  the  silk  loop  before 
passing  the  suture,  as  it  readily  happens  that  on  rapidly  drawing  the  needle 
out  with  the  holder,  the  short  silk  loop  attached  to  it  is  drawn  completely 


Fig.  228.— Wire-twister  (P.  F.  M.). 

through,  and  that  suture  is  lost.  If  the  wound  is  large  and  the  needle  can- 
not be  passed  underneath  the  whole  of  it  at  once  (as  in  peiineoiThaphy),  or 
if  the  mobility  of  the  part  renders  it  difficult  to  pass  the  needle  through 
both  lips  at  once  (as  in  trachelorrhaphy)  the  needle  must  be  brought  out 
at  about  the  middle  of  the  wound  and  immediately  reinserted,  and  it  is 
important  then  to  see  that  only  the  silk  is  drawn  out,  for  if  the  wire  were 
withdrawn  and  then  immediately  reinserted,  it  would  be  very  likely  to 
kink  and  occasion  trouble  when  the  whole  suture  is  drawn  through.  To 
allow  this,  the  silk  loojj  should  be  at  least  six  inches  long.    If  the  sutui'e  is 


Fig.  229.— Hemostatic  Forceps. 

very  long  and  there  is  a  possibihty  of  its  catching  in  its  track,  the  silk  and 
wire  may  be  smeared  with  carbolized  vaseline.  When  the  needle  has  been 
withdrawn  from  the  sound  flesh  opposite  its  j)oint  of  entrance,  which 
should  be  done  with  the  needle-forceps,  care  being  taken  not  to  nip  off  the 
point  of  the  needle,  it  is  well  to  take  the  silk  loop  in  the  left  and  the  wire 
in  the  right  hand,  and  by  a  rapid  backward  and  forward  motion  quickly 


426  GYITECOLOGICAL    OPERATION'S. 

draw  it  tlirougb.  In  this  way  catching  of  the  loop  or  accidental  kinking 
is  avoided.  An  assistant  can  help  the  operator  greatly  by  passing  the 
hook  of  a  tenaculum  under  the  needle  point  as  it  emerges,  and  holding  it 
up  so  that  the  ojperator  can  seize  it  with  the  needle-forceps  and  draw  it 
throuo-h.  When  the  time  comes  to  twist  the  wires,  the  two  ends  are 
seized  in  the  twister  (Fig.  228)  about  two  to  four  inches  from  the  wound 
(in  trachelorrhaphy  two  inches,  in  perineoiThaj)hy  four  inches),  the  free 
ends  are  cut  off  shox't  at  the  twister,  and  with  a  tenaculum  the  wire  is 
bent  over  the  line  of  the  wound,  a's  seen  in  Fig.  230.  The  object  of  this 
is  to  make  the  wire  when  twisted  compress  the  lips  of  the  wound  equally, 
and  not  cut  into  them,  as  it  would  do  if  simply  twisted  without  previous 
bending.  The  same  object  can  be  attained  by  separating  the  wires  after 
twisting  by  two  tenacula  passed  under  the  twist,  and  Thomas  has  devised 
a  special  instrument  hke  a  glove-stretcher  for  this  very  purpose.  But  the 
preliminary  bending  of  the  wire  is  the  best  method. 


Fig.  230.— Incorrect  and  Correct  Wire  Suture  (P.  F.  M.). 


The  shield  (Fig.  227)  is  then  passed  over  the  two  wires  and  pressed 
fii-mly  down  on  the  edges  of  the  now  united  wound,  and  the  wires  are 
rapidly  twisted  until  nothing  more  of  the  single  wire  can  be  seen.  The 
rule  is  to  t^^dst  until  the  triangle  fonned  by  the  junction  of  the  two  ends 
of  the  wire  becomes  obhterated,  because  then  we  can  be  sure  that  both 
ends  of  the  wire  are  in  apposition,  and  consequently  the  lips  of  the  wound 
also.  The  twisted  ends  are  then  cut  off  short  and  turned  do^vn,  or  left 
long  and  disposed  of,  as  hereafter  to  be  described.  In  approximating  the 
hps  of  the  wound,  tenacula  should  be  used,  whenever  needed,  in  order 
to  secure  smooth  apposition,  and  superficial  sutures  should  be  inserted 
as  occasion  may  require.  The  ends  of  the  wire  sutures  should  be  pre- 
vented from  injuring  neighboring  organs  either  by  being  turned  down,  as 
m  trachelorrhaphy,  or  by  being  covered  with  rubber  tubing,  as  in  perine- 
orrhaphy. Wire  sutures  may  be  left  undisturbed  for  ten  days,  which  is 
the  usual  time  for  remo\dng  them  ;  or,  if  thought  better,  they  may  be  re- 
tamed  for  two  weeks  or  longer.  In  removing  them  the  best  plan  is  to  grasp 
the  twisted  ends  with  long  dressing  forceps,  draw  on  them  gently  until 
the  separate,  ghstening  wire  appears,  and  then  cut  this  with  long  scissors, 
•withdrawing  the  sutui-e  over  the  line  of  union,  so  as  not  to  drag  it  apart. 


DisiXFECTioisr.  427 

The  suture-canals  generally  close  within  three  or  four  days  after  removal 
of  the  sutures,  A  pair  of  long,  straight  scissors  with  stout  points  will 
usually  answer  to  cut  the  sutures  ;  indeed,  I  employ  them  almost  wholly. 
Albert  Smith  has  devised  a  quite  useful  wii-e  scissors,  and  Bache  Emmet 
uses  another  of  his  own  iuTention. 


Fig.  S31. — Smith's  Wire-scissors. 

I  ought  to  say  here  that  wire  sutures  or  ligatures  are  now  but  little  used 
in  laparotomy,  certainly  not  within  the  abdominal  cavity,  their  use  in  gyne- 
cological surgery  being  restricted  to  operations  about  the  cervix,  vagina, 
and  perineum. 

4.  Disinfection. 

Disinfection  applies  either  to  the  suiToundings  of  the  patient,  to  the 
operator,  the  instruments,  or  the  wound  itself. 

It  goes  without  saying,  in  the  present  age  of  Listerism,  that  everything 
about  the  patient,  operating-room,  operator  and  instruments,  must  be 
scrupulously  clean  at  the  time  of  the  operation.  The  patient  should  have 
a  warm  soap-bath,  her  clothing  should  be  fresh  and  disinfected  ;  her  pubes 
or  labia  should  be  shaved  according  as  the  operation  is  respectively  either 
a  laparotomy  or  a  perineon^hajDhy.  The  operating-room,  whether  in  a  jiri- 
Tate  house  or  hospital,  should  be  thoroughly  disinfected  immediately  be- 
fore each  capital  operation,  the  walls,  ceiling,  and  floors  washed  with  a  one 
to  one  thousand  solution  of  corrosive  sublimate  ;  and  I  have  thought  it  best 
to  have  a  couple  of  five  per  cent,  carbolic  sprays  playing  in  the  room  for 
several  hours  before  and  during  the  operation. 

In  hospitals  the  ojDerating-room  is  kept  free  of  all  curtains,  hangings, 
carpets,  etc.  In  private  houses  it  is  best  to  remove  as  many  loose  articles 
of  drapery  as  possible,  and,  if  there  be  any  doubt  as  to  the  pui-ity  of  the 
carj^et,  the  latter  also.  For  minor  operations,  like  cen-ix  and  perineum  lac- 
erations, it  is  not,  however,  necessary  to  strip  the  room  of  all  these  things  ; 
only  for  capital  operations  is  it  wise  to  do  so.  Twelve  hours  before  the 
time  fixed  for  the  operation,  the  windows  of  the  room  should  be  closed  and 
the  room  filled  with  the  fumes  of  burning  sulphur,  or  of  pure  carbohc 
acid  poured  on  chloride  of  lime.  When  the  room  has  been  exposed  to 
these  fumes  for  two  or  more  hours,  the  windows  should  be  opened,  and 
the  room  thoroughly  aired,  and  then  the  windows  closed  again  and  the 
sprays  put  in  action.  The  temperature  of  the  room  should  be  about  75^ 
for  ordinary  operations,  about  85°  for  capital  operations.     Fresh  au'  may 


428  GYNECOLOGICAL    OPERATIONS. 

be  admitted  through  a  window,  even  during  a  capital  operation,  if  there 
be  no  draft  on  the  patient. 

Assistants  and  spectators  must  not  be  too  numerous,  and  must  not,  of 
com-se,  have  been  in  contact  wdth  any  infectious  or  contagious  disease 
within  the  last  forty-eight  hours. 

The  insti-uments,  after  having  been  scrupulously  cleansed  and  scrubbed 
with  emeiy-paper,  if  necessary,  are  bathed  in  a  five  per  cent,  solution  of 
carbohc  acid  (the  sublimate  tarnishes  them  too  much)  for  a  few  minutes, 
and  are  then  immersed  in  Listerine  poured  in  flat  pans,  in  wliich  they  are 
kept  during  the  operation.  I  prefer  this,  perhaps  rather  problematical 
dismfectant,  because  I  am  sure  that  the  properly  cleaned  instrument  can- 
not acquire  new  sources  of  infection  in  it,  and  because  it  does  not  irritate 
the  hands  hke  five  per  cent,  carbolic  acid  or  one  to  two  thousand  corrosive 
subUmate  solution,  when  they  are  exposed  to  them  for  some  time. 

Sponges  are  boiled  in  a  one  to  one  thousand  solution  of  corrosive  sub- 
limate, after  having  been  treated  as  described  on  p.  67.  During  the  oper- 
ation they  are  washed  in  a  one  to  two  thousand  solution  of  corrosive  subli- 
mate, which  is  made  by  pouring  one  tablespoonful  of  a  solution  of  corrosive 
sublimate,  of  the  strength  of  grs.  ij.  to  3  j-,  into  one  quart  of  water. 

The  genitals  of  the  patient  are  washed  with  a  one  to  one  thousand  solu- 
tion of  corrosive  sublimate,  immediately  before  the  operation,  and  after  it 
is  over,  the  wound,  if  it  be  an  abdominal  or  perineal  one,  is  kept  covered 
with  iodoform  until,  and  for  several  days  after,  the  stitches  are  removed. 
At  least,  in  hospital  practice  I  have  thought  best  to  do  this.  In  private 
practice  I  have  merely  covered  the  abdominal  wound  with  English  lint, 
soaked  in  a  one  to  three  thousand  solution  of  corrosive  sublimate,  changed 
as  often  as  the  dressing  is  renewed  ;  a  perineal  wound  I  have  merely  had 
syi'inged  off  several  times  daily  with  a  two  per  cent,  carbolized  solution. 
After  trachelorrhaphy  I  have  used  no  antisej)tics  except  two  per  cent,  car- 
bolized douches. 

The  hands  and  arms  of  the  ojDerator  and  his  assistants  should  be 
thoroughly  scrubbed  with  soap,  and  then  bathed  and  rubbed  with  a  one  to 
one  thousand  thymol  solution,  which,  if  the  operator  has  any  ordinary  re- 
gard for  clean  finger-nails  and  hands,  generally  ought  to  suffice  to  render 
him  aseptic.  A  clean  white  apron,  or  linen  coat,  and  entirely  fresh  clothing 
for  laparotomies,  should  be  worn  by  operator  and  assistants.  Cloths  and 
towels  used  during  the  operation  I  have  wrung  out  in  tepid  one  to  two 
thousand  corrosive  sublimate  solution. 

The  spray  over  the  abdominal  wound  during  laparotomy  seems  to  me, 
if  other  antiseptic  measures  and  thorough  cleanliness  are  observed,  entirely 
superfluous. 

5.  Anesthetics. 

The  anesthetic  usually  employed  for  gynecological  operations  in  this 
country  is  sulphuric  ether,  by  preference  that  manufactured  by  Squibb, 
of  Brooklyn.  Certainly  in  long  operations  ether  is  safer  than  chloroform  ; 
but  in  examinations  requiring  an  anesthetic,  or  in  operations  not  Hkely  to 
exceed  fifteen  or  twenty  minutes,  I  often  use  chloroform. 


ANESTHETICS. 


429 


The  best  ether  inhaler  in  my  opinion  is  that  of  Clover,  of  London, 
which  I  imported  several  years  ago,  and  have  since  used  exclusively  in 
private  practice.  The  accompanying  diagram  will  explain  its  use.  Its 
chief  advantages  are  :  ease  of  anesthesia,  and  saving  of  ether,  so  that  an 
operation  lasting  an  hour  will  usually  not  require  more  than  three  ounces 
of  ether.  This  point  is  of  especial  importance  in  capital  operations  where 
an  avoidance  of  shock  of  any  kind  is 
desirable.  A  disadvantage  is  its  ex- 
pense. The  old  paper  and  towel 
cone,  and  Allison's  inhaler  answer 
very  well  as  anesthetizers,  but  waste 
a  great  deal  of  ether,  affecting  not 
only  the  jDatient,  but  the  j)hysician 
who  administers  it. 

I  am  in  the  habit  of  giving  pa- 
tients, who,  of  course,  have  had  no 
meal  within  at  least  six  hours  before 
an  operation,  thirty  grains  of  bro- 
mide of  j)otash  about  an  hour  before 
and  one  or  two  ounces  of  whiske 
half  an  hour  before  the  anesthetic  i 
begun,  and  think  they  then  come 
more  easily  under  its  influence, 
and  have  less  vomiting.  I  always 
have  the  ether  given  by  a  competent 
assistant  upon  whose  caution  and  judgment  I  can  rely  ;  and  do  not  bring 
the  patient  into  the  operating  chamber  until  she  is  thoroughly  uncon- 
scious. 

I  need  hardly  go  into  details  here  as  to  how  to  give  ether,  since  the 
rules  for  that  process  are  common  to  all  surgical  operations.  I  would 
merely  say  that  retching  and  vomiting  during  anesthesia  call  for  more 
ether,  and  that  cyanosis  demands  fresh  air.  Further,  that  particular  atten- 
tion should  be  paid  to  the  respiration  of  the  patient  ;  a  woman  who 
breathes  well  is  not  liable  to  collapse  from  the  anesthetic,  even  if  her  ptdse 
is  a  little  feeble. 

Another  caution  which  has  been  impressed  upon  me  by  alarming  col- 
lapse after  three  operations  for  colpo-perineoiThaphy — one  in  my  hands, 
the  others  in  those  of  colleagues — is  not  to  lift  the  patient  into  an  ujDright 
position  after  long  anesthesia  until  she  has  fully  recovered  conscious- 
ness. 

In  case  of  cardi-asthenia  I  always  carry  nitrite  of  amyl  pearls  v\ith  me 
whenever  I  give  an  anesthetic. 

For  short  operations,  such  as  curetting  a  uterus,  removal  of  ui-ethral 
caruncles,  etc.,  that  is,  operations  not  exceeding  fifteen  minutes,  the  nitrous 
oxide  gas  answers  very  well  as  an  anesthetic. 

The  recent  innovation  of  etherization  by  the  rectum  has  thus  far  proved 
too  dangerous  (chiefly  through  over-distentiou  of  the  intestine,  and  coUi- 


FiG.  2.32.— Clover's  Ether  Inhaler. 


430  GYNECOLOGICAL    OPERATIOJSTS. 

quative  diarrliea)  to  commend  itself  to  my  favor,  even  as  a  means  of  be- 
ginning the  anesthesia. 

If  much  pain  is  complained  of  after  an  operation,  a  hypodermic  of  five 
to  ei"-ht  minims  of  Magendie's  solution  of  morphine  is  usually  advisable. 


THE  OPERATION  FOR  LACERATION  OF  THE  CERVIX  UTERL 

The  subject  of  the  significance  of  this  lesion,  of  the  evils  which  it  is 
claimed  to  entail,  and  the  benefits  which  foUow  its  repair  by  a  plastic  op- 
eration, has  attracted  so  much  attention  among  gynecologists  during  the 
past  decade  that  I  think  it  a  duty  to  myself  to  sui^plement  a  previous 
article  of  mine  {American  Journal  of  Obstetrics,  January,  1879),  by  a  com- 
plete statement  of  my  views  on  this  question.  In  doing  so  I  shall  endeavor 
not  only  to  describe  the  operation  for  this  injury  in  its  minutest  details, 
but  also  to  notice  and  discuss  from  the  latest  stand-point  the  various  dis- 
puted questions  of  the  indications  for,  and  results  of,  this  operation. 

Definition. — By  laceration,  fissure,  or  rent  of  the  cervix  uteri,  we  under- 
stand a  traumatic  division  of  the  lips  of  the  intravaginal  portion  of  the 
cervix  of  a  gTcater  or  lesser  degree,  and  involving  all  or  a  portion  of  the 
tissues  of  the  part.  Lacerations  of  the  upper  portion  of  the  cervix,  not 
involving  the  external  os,  are  not  included  in  the  lesion  now  under  consid- 
eration, being  classed  under  the  head  of  rupture  of  the  parturient  uterus. 

Etiology. — As  conveyed  by  the  word  "traumatic,"  in  the  foregoing  defi- 
nition, the  agency  which  produces  a  laceration  of  the  cervix  is  of  a  forcible 
character,  and  is  represented  by  the  presenting  part  of  the  child,  usually 
its  head.  The  rapid  forcing  of  this  presenting  part  through  the,  in  such 
cases,  as  yet  imperfectly  dilated  cervical  canal  and  external  os,  is  the 
cause,  in  the  large  proportion  of  instances,  of  the  rent.  Early  rupture 
of  the  membranes  before  the  cervix  has  become  softened,  dilated,  and  re- 
tracted over  the  presenting  part ;  and,  above  all,  unusually  severe  and  pro- 
tracted expulsive  efforts  of  the  uterus,  by  which  the  child  is  rapidly  forced 
through  the  cervical  canal  and  perhaps  out  of  the  vagina,  bear  the  chief 
blame  in  the  production  of  a  lacerated  cervix.  A  rigid  os,  faulty  develop- 
ment of  the  cervix  (conical,  protrusion  of  one  lip  over  the  other),  previous 
disease  of  the  cervix,  chiefly  cicatricial  induration  and  hyperplasia ;  mal- 
formation of  the  uterus  (anteflexion),  whereby  the  expulsive  force  during 
labor  is  dii-ected  more  against  one  lip  than  the  other  ;  cystic  disease  of  the 
cervix,  rendering  it  brittle  and  friable  ;  probably  contraction  of  one  or 
both  broad  ligaments,  or  adhesion  of  the  cervix  by  previous  cellulitic  ex- 
udation, preventing  equal  dilatation  of  the  lower  segment  of  the  utems  ;— 
all  these  conditions  doubtless  also  play  a  more  or  less  important  part  in 
the  causation  of  the  injury  under  discussion. 

That  it  can  be  produced  by  careless  or  unskilful  use  of  instruments, 
especially  the  obstetric  forceps,  in  rapidly  extracting  the  head  before  the 
OS  is  dilated,  cannot  be  denied.  Unquestionably,  in  a  certain  number  of 
cases,  the  lesion  owes  its  existence  to  this  cause,  and  the  operator  is  to 


OPERATION  FOR  LACERATION  OF  THE  CERVIX  UTERI.  431 

blame  for  its  occurrence.  But  the  number  of  lacerations  produced  by 
forceps  is,  I  am  confident,  exceedingly  small  in  proportion  to  the  whole 
number  of  lacerations,  and  even  to  the  number  of  forceps  of)erations.  In- 
deed, an  experienced  opei-ator,  by  gently  and  gradually  evolving  the  head 
and  regulating  its  progress  with  the  forceps,  may  even  prevent  a  ruj)ture, 
both  of  the  cervix  and  the  perineum. 

Besides,  the  poorer  classes,  with  whom  this  accident  is  certainly  met 
with  quite  as  frequently  as  in  the  rich,  very  generally  employ  midwives  in 
their  confinements,  who,  whatever  other  faults  of  commission  and  omission 
they  may  be  guilty  of,  do  not  use  forceps  in  delivering  their  patients. 

One  of  the  first  impulses  of  a  woman  when  she  is  informed  that  she  has 
a  torn  cer\'ix  upon  which  many  of  her  symptoms  depend,  is  to  blame  her 
physician  for  not  having  prevented  or  repaired  the  injury  at  once,  or,  at 
least,  for  not  having  told  her  of  it  and  of  the  necessity  for  future  treatment. 
In  conformity  with  justice  and  the  actual  facts,  I  have  always  strenuously 
insisted  on  the  complete  exoneration  of  the  medical  attendant  at  the  con- 
finement (even  though  it  was  a  midwife)  from  all  blame  in  the  production, 
or  failure  of  pi'evention,  or  immediate  repair,  of  the  injui-y  (which  I  would 
probably  not  be  as  well  justified  in  doing  if  the  injury  was  to  the  peri- 
neum) ;  but,  feeling  that  I  could  not  with  equal  j)roj)riety  excuse  the  ig- 
noring of  the  lesion,  I  have  preferred  to  pass  over  that  portion  of  the 
charge  in  silence.  It  will  naturally  and  correctly  be  inferred  that  I  con- 
sider it  a  wise  practice  to  examine  every  woman  immediately  after  con- 
finement, in  order  to  ascertain  if  the  cervix  or  perineum  has  been  lacer- 
ated, and,  if  the  latter  is  found  sufficiently  torn,  to  sew  it  up  at  once  ; 
but  if  the  cervix  is  the  part  injured,  to  make  a  later  examination  before 
discharging  the  patient  (say  in  a  month),  in  order  to  decide  whether  the 
rent  requires  further  treatment,  or  normal  involution  has  so  I'educed  its 
extent  as  to  render  it  insignificant.  The  latter  will  very  frequently  be 
found  the  case.  The  advice  given  by  some  obstetricians  to  sew  cer^■ical 
rents  at  once  is,  in  my  opinion,  usually  impracticable,  on  account  of  the 
difficulties  attending  such  an  operation  immediately  after  labor. 

I  do  not  think  that  I  go  too  far  when  I  assert  that  all  fissures  of  the  cer- 
vix which  give  rise  to  symptoms  or  entail  pathological  changes  in  the  pel- 
vis, are  the  result  of  parturition.  The  instances  where  the  cernx  has  re- 
mained fissured  sufficiently  to  demand  subsequent  operative  treatment, 
after  its  division  by  knife  or  scissors  for  dj-smenon-hea  or  sterility,  or  in 
the  removal  of  a  fibroid  tumor  of  the  uterus,  are  so  exceedingly  rare  as  to 
merit  no  notice  in  this  connection.  It  is  a  well-known  clinical  fact  that  a 
slit  of  a  non-parturient  cervix  can  with  difficulty  be  prevented  fi"om  closing, 
and  that  a  repetition  of  the  division  is  not  unfrequently  required.  The 
statements  of  certain  "  conservative  "  gynecologists,  that  the  followers  of 
the  modern  operative  school  vie  with  each  other  in  slitting  cervices  for 
sterility  or  dysmenorrhea,  and  then  in  sewing  up  these  same  slits,  are, 
therefore,  absui'd  and  absolutely  devoid  of  foundation,  theoretically  or  in 
fact. 

The  absence  of  preparation  of  the  lower  uterine  segment  and  cervix  for 


432  GYNECOLOGICAL    OPERATIONS. 

its  normal  function  of  dilatation  at  term,  is  the  reason  why  laceration  of  the 
cervix  is  so  liable  to  occur  during  premature  deliveries,  even  as  early  as 
the  second  month,  when  one  would  hardly  think  the  elastic  ovum  capable 
of  producing  such  an  injury.  Unquestionable  instances  of  this  occurrence, 
however,  after  early  abortions,  have  been  observed  by  many  gynecologists, 
and  I  have  met  vnth.  several  such  cases. 

Since  rigidity  of  the  inferior  uterine  segment,  tedious  labor,  and  instru- 
mental delivery  are  most  likely  to  be  present  duiing  a  first  confinement,  it 
is  as  a  result  of  the  first  labor  that  the  lai-ger  proportion  of  lacerations  oc- 
cm-.  Manifestly,  if  the  lesion  is  not  discovered  until  after  a  woman  has 
had  several  children,  it  is  usually  impossible  to  decide  in  which  labor  it 
occurred,  since  the  mere  recollections  of  a  woman  as  to  the  severity  of  a 
confinement,  perhaps  years  previously,  are  but  meagre  facts  on  which  to 
base  an  assumption.  And  it  is  possible  that  a  cei-vix,  like  occasionally  a 
perineum,  may  escape  unscathed  through  a  first  ordeal,  and  be  torn  at  a 
subsequent  labor.  But  the  probabihty  is  always  for  the  first  delivery,  and 
my  case-books  confirm  this  statement,  there  having  been,  in  612  lacerations 
in  parous  women,  146  primiparse,  and  310  others  in  whom  the  symptoms 
dated  from  their  first  child. 

Pathology. — The  first  pathological  result  of  a  parturient  laceration  of 
the  cends,  is  subinvolution  of  the  uterus,  either  of  the  cervix  alone,  or  of 
the  whole  organ.  As  a  rule,  normal  physiological  involution  of  the  sexual 
organs,  and  of  all  parts  of  the  body  involved  in  the  function  of  parturition 
(except  the  breasts  during  lactation),  is  accomplished  by  the  end  of  the 
second  month  after  confinement.  Various  circumstances,  which  it  is  not 
in  the  province  of  this  work  to  enter  upon,  may  retard  this  physiological 
process  of  retrograde  metamorphosis,  among  which  laceration  of  the  cervix 
stands  pre-eminent.  The  uterus,  instead  of  having  after  two  months  re- 
sumed, to  all  intents  and  purposes,  its  normal  ante-pregnant  shape,  size, 
and  histological  condition,  undergoes  this  process  imperfectly ;  it  is  larger 
(not  necessarily  longer),  heavier,  its  tissue  more  succulent  because  more 
hyperemic,  its  mucous  lining  pulpy  and  hypersecreting,  and  its  peritoneal 
covering  hyperesthetic.  In  course  of  time,  this  condition  of  subinvolution 
changes  to  hyperplasia,  the  succulent  tissue  becomes  dense  and  hard,  and 
the  uterus  anemic ;  the  minute  nerve-filaments  terminating  in  eveiy  mus- 
cular fibre  are  compressed  by  the  firm,  dense  areolar  tissue,  and  the  multi- 
tudinous neurotic  affections  grouped  together  under  the  term  hystero- 
neuroses,  make  their  appearance.  The  case  has  now  entered  on  its  chronic 
stage,  which  may  last  until  the  menopause  puts  an  end  to  sexual  activity. 

Not  only  the  uterus,  but  also  its  adnexa— ovaries,  ligaments,  and  cellular 
tissue— respond  to  the  retarding  influence  of  the  laceration  of  the  cervix 
during  involution.  We  thus  have  relaxed  ligaments,  congested  ovaries, 
and  edematous  cellular  tissue.  And  again,  in  course  of  time,  the  heavy 
uterus  drags  on  the  lax  ligaments  and  a  displacement  occurs  ;  the  ovaries 
change  their  hjq^eremia  to  hyperplasia,  and  the  shghtest  accidental  im- 
pulse may  Hght  up  an  inflammatory  process  in  the  ovaries,  the  cellular  tis- 
sue, or  the  pelvic  peritoneum.     Thus  ovaritis  and  cellulitis  are  frequently 


OPERATION    FOR    LACERATIOIST    OF    THE    CERVIX    UTERI.      433 

foimcl  in  connection  with  (and  probably  depending  on)  the  laceration. 
The  cellulitis  or  peritonitis  may  have  occurred  immediately  after  the  in- 
jury, and  thus  are  probably  to  be  explained  those  cases  in  which  the  rent 
extended  into  or  through  the  vaginal  vault,  and  the  cervix  is  found  bound 
down  by  cellulitic  exudation  or  is  drawn  to  one  side  by  the  contraction  of 
the  effused  lymph.  The  distressing  symptoms  joroduced  by  these  several 
pathological  conditions  must,  of  course,  be  included  in  the  list  of  those  fol- 
lowing laceration  of  the  cervix,  as,  indeed,  they  are  frequently  the  only 
ones  for  which  the  patient  seeks  advice. 

In  addition  to  these  changes  in  the  uteinis  proper  and  its  adnexa,  the 
cervix  undergoes  certain  alterations  of  almost  equal  importance.  The  lac- 
erated lips  become  glazed  over  by  cicatricial  tissue,  which  occludes  the 
orifices  of  the  cervical  glands,  and  occasions  retention  of  their  contents  and 
a  swelling  of  the  cervix  by  the  distended  glands  ;  the  cicatrix  also  presses 
on  the  terminal  nerve-filaments  in  the  cervix,  chiefly  in  the  upper  angle  of 
the  rent,  and  through  communication  with  the  sympathetic  sj'stem  pro- 
duces reflex  neuroses  in  the  pelvis,  down  the  thighs,  along  the  back,  and 
in  different  distant  portions  of  the  body.  The  relation  between  some  of 
these  neuroses  and  the  laceration  is  so  mysterious  as  to  be  inexplicable, 
and  is  not  credited  by  many  gynecologists  ;  but  numerous  cases  are  on 
record  in  which  the  repair  of  the  laceration  by  a  plastic  operation  has  se- 
cured a  cure  of  the  neuroses,  and  hence  this  relation  would  seem  to  have 
been  proved  in  such  instances.  These  neuroses  may  be  either  of  a  physi- 
cal or  mental  character,  from  a  simple  neuralgia  to  a  chorea  or  functional 
dementia, 

Emmet  claims  that  general  anemia  from  defective  innervation  of  the 
nutrient  organs  is  one  of  the  results  of  reflex  neurosis  from  a  lacerated 
cervix.  He  is  positive  in  this  statement,  although  most  gynecologists  have 
not  yet  accepted  his  view  in  all  its  bearings. 

Whether  the  obstructed  glands  exert  an  irritating  influence  or  not  on 
the  terminal  cervical  nerves,  is  a  question  to  be  considered.  I  incline  to 
an  affirmative  view. 

If  the  lacerated  cervix  does  not  cicatrize  over,  or  only  the  angles  of  the 
rent  heal,  the  remainder  of  the  lips  may  undergo  cystic  or  jjapillary  hyper- 
plasia, or  both  ;  the  separated  lips  evert,  the  mucous  membrane  lining  the 
cavity  of  the  cervix  is  rolled  out  (a  condition  called  ectropion),  its  epithe- 
lium is  gradually  rubbed  off,  and  a  hyperplasia  of  the  cysts  and  papillfe  of 
the  exposed  mucous  membrane  takes  place.  From  this  swollen,  granu- 
lating surface  oozes  a  profuse,  glairy,  discolored  discharge,  and  slight 
traumatic  hemorrhages  are  frequent.  This  hyperemic  and  hypeii)lastic 
condition  often  extends  upward  to  and  even  beyond  the  internal  os,  and 
cervical  and  corporeal  endometritis  result,  in  the  latter  aftection  frequently 
attended  by  the  formation  of  fungosities.  In  consequence  we  have  nienor- 
rhagia,  which  may  become  so  profuse  as  to  endanger  the  life  of  the  pa- 
tient. Profuse  menstruation  may  also  occur  merely  from  the  subinvolu- 
tion, when  no  fungosities  are  present. 

The  subinvolution  and  its  ultimate  consequences  (among  which  retro- 
28 


434 


GYNECOLOGICAL    OPERATIONS. 


displacement  and  descensus  of  the  uterus  and  hyperplasia  play  the  most 
important  rule),  the  cervical  catarrh,  the  menorrhagia,  the  neuroses,  the 
tendency  to  cellulitis — these  are  assui-edly  sufficiently  grave  conditions  to 
give  to  laceration  of  the  cervix  a  prominent  place  in  the  production  of 
utero-pelvic  disease.  Fortunately,  all  these  jDathological  results  are  seldom 
found  in  the  same  case. 

There  is  one  other  j)ossible  ultimate  result  which  merits  mention 
through  its  gravity,  when  it  happens  to  occiu\  It  is  the  possible  degener- 
ation of  the  raw,  hyperplastic,  everted  surface  of  the  torn  cervix  into  malig- 
nant disease,  epithelioma.  The  cases  are  constantly  multiplying,  since 
Breisky  and  Emmet  called  attention  to  this  occurrence,  where  in  carcinoma 
of  the  cervix  the  original  existence  of  a  deep  laceration  can  be  recognized, 
and  the  inference  of  cause  and  effect  is  undeniable.  I  myself  have  ob- 
served several  undoubted  cases  of  this  kind.  In  this  fearful  j)rospect, 
which  if  remote,  is  still  possible,  lies  another  reason  why  a  laceration  of 
the  cendx  should  not  be  neglected  when  discovered  in  good  season.  How 
many  cases  of  the  "ulceration  of  the  cervix"  of  our  forefathers  have  thus 


^P^p°-i'^^-";^°'™^-  ^^"lt^P^'^°"''  Os  Fig.  234. -Eight  Unilateral  Laceration  of  Cervijc 
(i:'.  t.  M.).    All  cervix  cuts  are  drawn  fP    F   M  t 

as  seen  through  a  Sims"  speculum  with  '        * 

the  patient  on  the  left  side. 

been  neglected,  or  cauterized  for  months,  only  to  terminate  ultimately  in 
carcinoma,  we  can  but  conjecture,  and  rejoice  in  the  possession  of  instru- 
ments and  knowledge  at  the  present  day  (thanks  to  Sims  and  Emmet) 
which  permit  us  to  diagnose  and  repair  this  injury  before  it  is  too  late. 
When  no  eversion  of  the  torn  hps  takes  place,  we  may  stiU  have  subinvo- 
lution, cervical  cataiTh,  and  reflex  neuroses  ;  but  generaUy  the  local  and 
general  effects  of  the  laceration  are  much  less  marked  than  when  the  lips 
are  everted. 

In  a  certain  proportion  of  cases,  laceration  of  the  cervix  produces 
neither  subinvolution  nor  any  of  the  results  above  described,  and  there- 
fore requires  no  treatment.  And  it  is  equally  true  that  subinvolution, 
ovaritis,  chi'onic  cellulitis,  cystic  and  papillary  hypei-plasia  of  the  cervical 
endometrium,  endometritis,  etc.,  may  occur  from  other  causes  than  a  lac- 
erated ceiwix.  But  occurring  together  with  a  laceration,  it  is  generally 
lair  to  assume  that  they  depend  on  it. 

Freque^nxy.— The  assertion  may  fairly  be  made  and  proved,  that  very 


OPERATION    FOE   LACERATION    OF    THE    CERVIX    UTERI.      435 

few  women  are  confined  at  term  without  sustaining  some  injury  to  the 
cervix,  be  it  ever  so  sHght.  It  is  the  rare  exception  to  examine  a  woman 
who  has  had  a  chUd  and  to  find  the  hps  of  the  external  os  entirely  smooth 
without  the  slightest  nick  or  fissure.  And,  as  already  stated,  abortions 
even,  frequently  produce  this  lesion.  As  a  rule,  the  conditions  which  pre- 
dispose or  cause  the  laceration  obtain  during  the  first  labor,  and  hence  we 
can  generally  attribute  the  accident  to  that  delivery.  The  number  of 
labors  which  a  woman  has  had  does  not  therefore  specially  influence  the 
occurrence  of  a  cervical  rent,  although  each  labor  may  enlarge  the  fissure 
and  aggravate  the  ectropion  and  the  other  sequelse.  The  lesion  is  there- 
fore an  exceedingly  frequent  one,  and  the  degrees  and  varieties  of  it 
which  come  under  observation  for  diagnosis  and  treatment  are  proportion- 
ally common.     Emmet  goes  so  far  as  to  say  that  "  at  least  one-haK  of 


Fig.  235. — Bilateral  Laceration  of  Cervix.  Fig.  236. — Bilateral  Laceration  of  Cervix.      Second 

First  degree  (P.  F.  M.).  dej^ree  (P.  F.  M.).     ' 

the  ailments  among  those  who  have  borne  children  are  to  be  attributed  to 
lacerations  of  the  cervix."  Fallen  claims  that  forty  per  cent,  of  women 
with  uterine  disease  have  a  lacerated  cervix.  Goodell  states  "  that  about 
one  out  of  every  six  women  sufi^ering  from  uterine  disease  has  an  un-vmited 
laceration  of  the  cervix,"  and  other  vsn-iters  have  aiTived  at  an  estimate 
vai-ying  between  these  figures.  I  found  among  2,500  parous  women  (i.e., 
those  who  had  born  one  or  more  children),  612  cases  of  well-marked  lac- 
eration of  the  cervix,  or  about  25  per  cent.  Of  these  only  280  were  of 
sufficient  depth  to  produce  symptoms  and  require  treatment ;  the  propor- 
tion of  deep  rents,  therefore,  or  of  such  as  are  likely  to  produce  the  j^atho- 
logical  conditions  already  described,  was  less  than  fifty  per  cent.  In  the 
remainder  the  rents  were  either  too  shallow  to  be  of  any  consequence,  or 
they  had  filled  out  and  cicatrized  over  and  gave  lise  to  no  s}-niptoms. 

It  will  thus  be  seen  that,  while  recognizing  the  frequency  of  the  occur- 
rence of  this  lesion  during  parturition,  I  esteem  but  a  comparatively  small 
proportion  of  all  the  cases  of  sufficient  pathological  importance  to  merit 
recognition  as  factors  in  the  production  of  uterine  disease. 

Varieties  and  Degrees. — The  parturient  cenix  uteri  may  be  lacerated 
in  one  or  several  places  and  at  any  point  of  its  circumference.  The  forms  of 
laceration  usually  met  with  are  the  following  :  unilateral,  bilateral,  anterior, 


436 


GYlSrECOLOGICAL    OPEEATIONS. 


posterior,  stellate,  multiple  (Figs.  234  to  238).  Of  tliese  the  bilateral  is 
the  most  common,  the  unilateral  the  next,  and  the  stellate,  multiple,  pos- 
terior, and  anterior,  follow  in  the  order  named.  The  bilateral  laceration 
(Figs.  235,  236,  237),  as  its  name  implies,  takes  place  on  either  side  of  the 
cervix  toward  the  lateral  vaginal  pouch  ;  the  unilateral  (Fig.  234),  may  be 


Fig.  237. — Bilateral  Laceration  of  Cervix.     Third  degree  (P.  F.  M.).     The  two  tenacula  show  the 
direction  of  approximation  of  the  everted  lips. 

either  on  the  left  or  on  the  right  side,  more  commonly,  in  my  experience,  on 
the  left.  The  reason  for  this  is,  I  think,  correctly  supposed  to  be  the  predom- 
inance of  left  occipito-anterior  presentations,  and  the  greater  tendency  to 
rupture  by  the  broad  unyielding  occiput  than  by  the  comparatively  small 
foi-ehead  and  soft  face,  if  these  rents  extended  originally  up  to,  or  even 
into,  the  vaginal  vault,  very  often  a  linear  cicatrix  is  found  leading  for  an 
inch  or  more  away  from  the  upper  angle  of  the  tear,  and  not  unfrequently 
binding  down  or  dragging  on  the  cervix.     At  times,  also,  a  distinct  patch 


Fia.  2.38.-SteIlate  Laceration  of  Cervix  Fig.  230._Laceration.  First  Degree,  with 

If.  I'.M.).  large   Cystic   Degeneration  of  the  Anterior 

Lip  (P.  F.  M.). 

of  hard,  plastic  exudation  is  felt  above  the  rent  in  the  parametran  cellular 
tissue,  which  was  evidently  caused  by  the  same  traumatic  influence  which 
produced  the  rent. 

In  the  stellate  laceration  (Fig.  238)  the  fissures  extend  in  a  star-shaped 
du:ection  from  the  lips  of  the  external  os  ;  they  may  reach  entirely  to  the 


OPEKATION    FOE    LACERATION    OF   THE    CERVIX    UTERI.      437 

vaginal  vault,  but,  as  one  might  exjDect  from  the  greatei'  distribution  of 
force  on  the  cervical  zone  and  more  uniform  yielding  of  the  tissues,  the 
rents  are  usually  not  so  deep  as  in  the  lateral  varieties. 

The  multiple  laceration  is  characterized  by  numerous  small,  shallow 
nicks  in  the  edges  of  the'  external  os,  which  give  the  lips  of  the  os  an  irregu- 
lar, rough  feel,  but  which  generally  produce  no  symptoms  and  require  no 
treatment.  I  mention  this  variety  merely  for  sake  of  completeness,  not 
because  it  is  therapeutically  important. 

The  anterior  and  posterior  lacerations  resemble  in  appearance  the  lat- 
eral, with  the  exception  that  the  lips  of  the  rent  are  usuall}'  not  so  widely 
separated,  owing  to  the  comparative  absence  of  traction  on  them  b^^  the 
uterine  ligaments  and  the  apposition  of  the 
lateral  vaginal  walls.  I  can  recollect  see- 
ing but  few  anterior  rents  of  any  extent  ; 
of  the  posterior  I  have  seen  quite  a  number, 
some  extending  even  into  the  posterior  va- 
ginal vault,  the  cervix  being  bound  down  by 
posterior  adhesions. 

There  is  another  form  of  laceration, 
which  does  not  properly  come  under  the 
head  of  fissure  of  the  lips  of  the  external 
OS,  since  it  consists  merely  in  a  sundering        ^^^  240.-conceaiedFis.nre.sof  Cer- 

Of    certain    circular    muscular    fibres    of    the      ^ical   substance  not  involving  External 

Os,  but  proilucing  Patulousness  of  that 

upper  portion  of  the  cervix,  and  a  lacera-  Orifice  (p.  f.  m.). 
tion  of  the  endotrachelian  mucous  membrane  ;  the  result  of  which  is  sub- 
involution of  the  whole  part,  whereby  the  external  os  is  kept  gaping  and 
the  cervical  cavity  is  exposed  to  the  air,  if  not  to  friction.  The  vaginal 
covering  of  the  cervix  is  uninjured.  The  result  of  this  exposure  is  to  pro- 
duce a  cervical  catarrh,  which  is  exceedingly  difficult  of  cure  so  long  as 
the  OS  continues  to  gape.  This  variety  should  be  properl}'  considered  as 
a  subinvolution  of  the  cervix  with  paralysis  of  the  circular  fibres,  produced 
by  their  hidden  rupture  (Fig.  240). 

The  relative  frequency  of  these  varieties  and  degrees  of  laceration  is  as 
follows  :  Among  the  612  cases  mentioned,  there  were  bilateral,  340  ;  uni- 
lateral, 120  (left,  80,  right,  40)  ;  anterior,  7  ;  posterior,  12  ;  stellate,  11  ;  re- 
mainder not  noted.     First  degree,  272  ;  second,  169  ;  third,  or  worst,  171. 

Pathological  Changes  in  the  Lacerated  Cervix. — In  addition  to  the  mechan- 
ical lesion  represented  by  the  rent  itself,  certain  pathological  conditions  in 
course  of  time  develojj  on  the  torn  surface  or  in  the  substance  of  the  cerAix, 
which  frequently  give  rise  to  symptoms  and  require  treatment  not  at  all 
called  for  by  the  simple  tear  itself. 

The  first  of  these  conditions,  not  in  itself  pathological  but  rather  repara- 
tive, is  the  formation  of  a  cicatrix  over  the  torn  surface.  This  eftect  of 
nature  to  repair  the  injury  in  very  many  cases  meets  with  success  ;  but  in 
a  not  inconsiderable  proportion  nature  appears  to .  overdo  her  work  and 
to  supply  a  cicatrix  more  than  necessarily  thick  and  unyielding.  The 
results  of  this  is,  that  the  contracting  cicatricial  tissue  produces  deformity 


438  GYNECOLOGICAL    OPEEATIONS. 

of  the  lips  of  the  cervix  ;  that  the  numerous  glands  in  the  cervix  are  closed 
and  thereby  become  distended  with  mucus,  and  cause  hj'pertrophy  of  the 
whole  organ  (so-called  cystic  hyperplasia)  ;  and  finally,  that  the  dense  cica- 
tricial substance,  by  compressing  the  terminal  nerve-filaments,  gives  rise  to 
multitudinous  and  diverse  reflex  neuroses  in  other  parts  of  the  body,  from 
which  the  patient  seeks  rehef.  According  to  Emmet,  it  is  chiefly  the 
pressm-e  in  the  upper  angle  of  the  rent  by  the  so-called  "cicatricial  plug," 
which  occasions  these  neuroses.  Even  in  comjDaratively  small  rents,  which 
of  themselves  would  produce  neither  symptoms  nor  call  for  treatment, 
these  "  cicatricial  plugs  "  are  said  to  be  at  the  "  root  of  all  evil  "  in  the  case. 

A  second  compHcation  is  the  rolling  out  (like  a  split  celery  stalk,  as 
Goodell  has  it)  of  the  lips  of  the  torn  cervix,  which  is  caused  joartly  by  the 
natui-al  tendency  of  the  flaps  of  a  divided  elastic  tube  to  sejDarate  when  its 
circular  fibres  are  cut,  and  chiefly  by  the  traction  exerted  on  either  lip, 
anterior  and  posterior,  by  the  attachments  of  the  adjacent  organs  (vagina, 
bladder,  rectum,  and  respective  ligaments)  to  the  part,  when  the  patient  is 
in  the  erect  position.  In  the  minor  degrees  of  the  lesion,  the  eversion,  or 
ectropium,  is  but  slight,  and  but  a  small  portion  of  the  cervical  canal  is 
rolled  out  and  exposed  ;  but  when  the  rent  extends  to  the  vaginal  junction 
and  is  bilateral,  the  whole  cervical  canal  up  to  the  internal  os  may  be  laid 
open  and  the  tips  of  the  everted  lijDS  may  touch  the  anterior  and  posterior 
vaginal  walls  respectively. 

If  the  eversion  is  unilateral  the  ectropium  is  usually  much  less,  but  I 
have  seen,  even  in  that  case,  the  cervical  canal  laid  bare  above  the  vaginal 
insertion.  In  anterior  and  posterior  rents  there  is  usually  very  little  ever- 
sion. 

It  must  not  be  assumed  that  every  cervical  rent  is  covered  by  dense, 
unyielding  cicatricial  tissue,  nor  that  eversion  always  takes  place.  Indeed, 
I  have  seen  many  cases  where  merely  a  fine  film  of  vascular  membrane 
covered  the  originally  raw  surfaces  of  the  rent ;  and  I  have  met  with 
numerous  instances  of  even  the  deepest  fissiu^es  with  no  eversion  whatever. 

As  a  resiilt  of  the  fissure,  the  proper  puerperal  involution  of  the  cervix 
does  not  take  place  ;  the  cicatricial  coating  interferes  with  the  normal  dis- 
charge of  mucus  fi-om  the  numerous  cervical  glands;  in  consequence  of  this 
and  the  chronic  passive  hyperemia  of  the  part  maintained  by  the  irritation 
of  the  tear,  there  is  a  hyperplasia  of  all  the  elements  of  the  cervix,  and  the 
whole  part  becomes  decidedly,  often  enormously,  enlarged.  The  exposed 
mucous  membrane  of  the  cerrical  canal  becomes  thickened,  granulations 
spring  up,  and  the  glands  develop  into  mucous  polypi  (Figs.  239,  241, 
and  242).  By  friction  against  the  vaginal  walls  during  walking,  through 
coition,  and  the  softening  of  the  epithelium  of  the  diseased  part  by  the 
constant  discharge,  a  raw,  eroded  surface  soon  forms,  on  which  the  swollen 
papilla;  and  distended  foUicles  are  clearly  visible,  and  from  this  erosion  oozes 
a  profuse,  serous  fluid  which  mingles  with  the  thick,  glairy,  discolored 
mucus  discharged  in  abundance  from  the  gaping  cervical  canal.  The  ap- 
pearance of  such  a  swollen,  hyperemic,  and  eroded  cervix,  with  its  everted 
hps  studded  mth  papillary  excrescences,  may  so  closely  resemble  epitheli- 


OPERATION  FOR  LACERATION"  OF  THE  CERVIX  UTERI.   439 

oma  as  to  mislead  the  beginner,  and  even  compel  the  experienced  specialist 
to  call  the  microscope  to  his  aid  in  deciding  between  the  two  affections 
(Fig.  243). 

Such  an  erosion  should  never  be  mistaken  for  an  ulceration,  as  was 
done  for  many  years,  until  Emmet  recognized  and  described  the  true, 
nature  of  the  condition.  An  ulceration  always  implies  a  loss  of  sub- 
stance, an  excavation;  an  erosion,  such  as  that  described,  on  the  lacerated 
cervix,  is  not  only  not  an  excavation,  but  very  often  there  is  an  elevation, 
an  actual  increase  of  tissue  through  the  hiy-perplasia  above  mentioned. 
So  long  .as  the  parts  retain  their  homogeneous  character — I  mean,  so 
long  as  the  sloughing  peculiar  to  carcinoma  does  not  replace  the  benign 
erosion  of  the  laceration — so  long  an  "  ulceration  "  j^roper  of  the  cervix  is 
not  found  in  this  condition. 

It  will  be  readily  understood  that  the  various  irritations  to  which  the 
gaping  cervical  canal  is  exposed,  soon  develop  a  hypersecretion  of  that 
part,  which  increases  as  the  glands  become  hyperj)lastic  and  the  cervical 
endometrium  is  more  and  more  rolled  out.  A  profuse  catarrhal  endo- 
trachelitis  is  therefore  the  natural  accompaniment  of  many  cases  of  cervical 
laceration,  and  often  its  only  troublesome  symptom.  In  a  rather  small 
proportion  of  cases,  I  think,  the  catarrh  exists  without  eetroj)ium  of  the 
cervical  lining,  and  I  am  inclined  to  attribute  the  hyjoersecretion  to  a  sul> 
involution  of  the  cervical  glands  after  the  last  confinement.  Indeed,  I  be- 
lieve this  subinvolution,  due  in  itself  to  the  laceration,  to  be  part  cause  of 
the  chronic  endotrachehtis  in  many  cases,  even  before  the  subsequent  cystic 
h^q^erplasia  develops.  I  cannot  divest  myself  of  the  ojDinion  that  laceration 
and  cervical  catarrh  hold  the  relation  toward  each  other  of  cause  and  effect, 
primarily  at  least,  in  spite  of  the  view  exjDressed  by  Schroeder  and  other 
prominent  authors,  that  the  tear  occurs  because  the  cervix  is  degenerated 
and  softened  by  the  hypersecretion.  If  the  latter  \iew  were  correct,  lacer- 
ation should  be  less  frequent,  for  chronic  catarrh  of  the  cervix  in  the  nul- 
lipara is  not,  in  my  experience,  a  very  common  disease. 

Degrees. — In  accordance  with  the  depth  of  the  laceration;  we  may  dis- 
tinguish three  degrees  of  the  lesion  :  the  first,  in  which  the  rent  extends 
only  a  short  distance  into  the  tissue  of  the  cervix,  say  one-quarter  of  an 
inch  (Fig.  235)  ;  the  second,  where  the  fissure  reaches  about  half-way  to 
the  vaginal  reflection  (Fig.  236)  ;  and  the  third,  or  icorst  degree,  Avhere  the 
cervix  is  torn  up  to,  or  even  into,  the  vaginal  vault  (Fig.  237).  This  diA-is- 
ion  is  an  arbitrary  one,  but  seems  to  cover  the  majority  of  cases. 

If  the  cervix  is  short,  the  length  of  the  rent  will  naturally  vary.  Thus, 
a  laceration  of  the  third  degree  in  a  short  cer\-ix  may  appear  ver\-  shallow, 
and  equal  only  to  one  of  the  first  or  second  degree  in  a  long  cer-\-ix.  But 
the  degree  must  be  estimated  by  the  depth  of  the  rent,  not  by  the  length 
of  the  cervix. 

The  depth  of  the  laceration  will  be  apparently  much  increased  if  an 
eversion  of  the  lips  and  ectropium  of  the  cervical  lining  membrane  is  pres- 
ent. The  bright  red,  or  raw,  everted  surface  gives  an  exaggerated  appear- 
ance of  the  extent  of  the  fissure,  the  true  hmits  of  which  are  easily  recog- 


440 


GYNECOLOGICAL    OPEKATIOJSTS- 


iiized  by  ascertaining  the  distance  between  the  ui^i^er  angle  of  the  rent  and 
the  external  os  and  vaginal  vault  resijectively.  The  deeper  the  rent,  the 
greater  will  be,  as  a  rule,  the  eversion  and  ectropium,  and  the  larger  the 
raw,  eroded  surface  exposed  to  view.  It  will  thus  appear  evident  that  a 
lacerated  cervix  may  often  acquire  a  pathological  imj^ortance  chiefly  in 
consequence  of  the  eversion  of  its  lips,  and  that  it  is  this  eversion  rather 
than  the  rent  itself  which  produces  symptoms  and  calls  for  treatment. 

Precisely  the  same  statement  aj)plies  to  the  condition  which  I  have  al- 
ready described  as  hyperplasia  of  the  papillae  and  cysts  of  the  cervix,  when 
it  complicates  a  laceration.  The  swollen  papillae  and  distended  foUicles 
produce  an  enlargement  of  the  cemx,  one  lip  usually  predominating ;  in 
consequence,  the  torn  lips  are  forced  apart,  and  more  of  the  hypeiiolastic 
endotrachehan  mucous  membrane  appears  to  view  than  the  size  of  the  rent 


Fig.  241.— Slight  Bilateral  Laceration,  with 
Cystic  Erosion  of  both  Lips  (P.  F.  M.). 


Fig.  242.— Posterior  and  Bilateral  Laceration, 
with  Cystic  Hyperplasia  (P.  F.  M.). 


waiTants,  and  the  lesion  thus  appears  magnified  when,  in  fact,  it  is  but  one 
of  the  sequelae  of  that  lesion,  the  hyperplasia  of  the  cervix,  ivhich  gives  it 
that  appearance.  The  illustrations  (Fig.  241,  242,  and  243),  compared  to 
that  depictmg  simple  eversion  without  hyperplasia  (Fig.  235),  plainly  show 
the  effects  of,  and  the  difference  between,  these  two  conditions. 

SmPTOMS.— The  physical  signs  which  may  be  present  as  the  result  of 
a  laceration  of  the  cervix  are  either  local  or  general,  or  both. 

Local-These  Rve  usually  the  more  prominent,  and  first  attract  the  at- 
tention of  the  patient  to  her  sexual  organs,  and  lead  her  to  seek  ad^dce. 
Iheir  nature  may  readily  be  imagined  from  the  description  already  given  of 
he  patho  ogical  changes  in  the  sexual  organs  following  laceration,  and  I 
shal  merely  enui^erate  them,  ^vith  brief  comments,  as  occasion  may  require. 

I  Pai;^-;  tl  "^  '^  '"''^^^'  "  bearing-down,"  dragging,  in  the  pelvis  ; 
cha!al  .  "^%'^^-^™  -8---' l^il-^  and  thighs,  of  a  darting,  lancfnating 
o^at  '  ^'"^T'^^''  '^"^^  "^  ^^'  cervico-uterine  variety;  5.  Men^ 
r  unh  %7--"V-trorrhagia,  especially  after  coition  ;' 6.  Dyspa- 
leunia  ,  7.  Sterihty  ;  8.  Habitual  miscarriage. 

The  vanous  sensations  of  weight,  "bearing  down,"  and  duU  pain,  are 


OPERATION"  FOR  LACERATION  OF  THE  CERVIX  UTERI.   441 

common  to  the  majority  of  uterine  diseases ;  the  cervical  leucorrhea  may 
Le  present  in  nulliparise,  and  the  menorrhagia  be  due  to  chronic  endome- 
tritis, fibroids,  etc. ;  the  metrorrhagia  dui'ing  coition  may  be  jjroduced  by  sim- 
ple erosion,  or  by  cancer  of  the  cervix  ;  the  dyspareunia  will  also  be  found 
in  chronic  pelvic  inflammation,  prolapse  of  congested  ovaries,  etc.,  and 
the  causes  of  sterility  are  too  various  to  mention  here  ;  habitual  miscar- 
riage may  be  due  to  degeneration  of  the  ovum  or  endometrium,  or  to  con- 
stitutional causes.  It  is  thus  apparent  that  none  of  the  above  symptoms  are 
pathognostic  of  laceration  of  the  cervix  uteri ;  but  when  several  occur  to- 
gether that  diagnosis  may  be  plausible.  Of  course,  it  is  unusual  for  all 
these  symptoms  to  be  found  in  one  case,  some  being  present  in  one,  others 
in  another  case. 

Geneml.—The  longer  the  laceration  has  existed,  the  greater  its  de- 
gree, and  the  more  marked  the  local  symptoms  above  described,  the  more 
^vill  the  general  health  of  the  patient  be  affected.  The  long- continued 
suffering,  the  drain  of  albuminous  matter  through  the  profuse  cen-ico- 
uterine  leucorrhea,  the  menorrhagia,  and  perhaps  repeated  abortions,  all 
gradually  bring  on  a  most  decided  state  of  anemia,  in  consequence  of 
which  digestion  suffers,  and  the  patient  ultimately  becomes  a  chronic  in- 
valid. 

The  mode  of  production  of  general  anemia  through  these  agencies 
is  sufficiently  obvious  not  to  require  further  explanation.  But  there  is  a 
theory,  of  which  Emmet  is  the  originator  and  chief  advocate,  for  this 
anemia,  which  is  less  self-evident  and  plausible,  and  is  not  as  yet  generally 
adopted.  Emmet  claims  to  have  seen  patients  in  w^hich  the  "  cicatricial 
plug "  was  particularly  well  developed,  with  severe  anemia,  recover  from 
their  anemia  and  regain  their  health  after  excision  of  the  plug  and  union 
of  the  rent  by  sutures.  His  theory,  deduced  from  these  cases  and,  he 
thinks,  jDroved  by  them,  is  that  a  reflex  neurosis  from  the  terminal  nei-ve 
filaments,  compressed  in  the  cicatrix,  is  distributed  through  all  the  nerves 
in  charge  of  nutrition,  disturbing  their  functions  and  impoverishing  the 
blood.  And  this  entirely  independently  of  the  depressing  effect  of  the  va- 
rious reflex  neuralgise,  w^hich  certainly  seem  to  depend  on  the  cervical 
lesion.  The  opinion  of  so  exjDerienced  a  gynecologist,  and  keen  and  relia- 
ble observer,  as  Emmet,  merits  careful  consideration,  respectful  attention, 
and  conditional  accej)tance,  subject  to  disproval  by  positive  facts.  Hence 
we  have  no  right  to  scoff  at  this  theory,  however  strange  it  may  seem,  that 
so  slight  a  pathological  factor  as  an  apparently  quite  harmless  scar  in  an 
otherwise  almost  insignificant  tear  of  the  neck  of  the  womb,  should  be 
cajDable  of  producing  such  wide-spread  constitutional  disturbance.  "When 
a  scar  may  be  the  starting-point  of  tetanus,  we  cannot  denj'  the  possibility 
of  a  reflex  disturbance  of  the  general  nei'vous  system  from  so  slight  a 
focus  as  an  old  scar  on  the  cervix  uteri.  That  this  view  of  Emmet  exer- 
cises an  important  influence  on  the  significance  of  a  laceration  and  on  the 
indications  for  its  reiDair,  is  evident.  A  believer  in  this  theory  must  attrib- 
ute symptoms  to,  and  advise  operative  treatment  of,  a  perfectly  healed 
laceration,  in  which  no  other  evidence  of  the  lesion  is  appai-ent  but  the 


44:3  GYNECOLOGICAL    OPERATIONS. 

groove  separating  the  torn  lips,  neither  hyperplasia  nor  erosion  of  the  lips, 
nor  cervical  leucorrhea  being  present ;  v^'hile  to  the  majoiit}'  of  physicians 
such  a  state  of  the  cervix  would  seem  utterly  incapable  of  producing  local 
or  o-eneral  pathological  symptoms  of  any  kind  whatever,  and  consequently 
would  require  no  treatment. 

"While  I  have  not  met  with  cases  which  to  my  mind  positively  proved 
the  correctness  of  Emmet's  theory,  I  have  seen  several  instances  of  reflex 
neuroses  affecting  other  functions  and  organs  than  those  of  nutrition,  clearly 
dependent  on  a  perfectly  cicatiized  cei-vical  rent.  In  one  case  a  lady  had 
had  one  child  eighteen  years  jDreviously  ;  since  then  she  had  suffered  from 
violent  attacks  of  hemicrania  coming  on  always  at  the  menstrual  period, 
and  also  at  irregular  intervals  on  any  excitement.  She  also  had  a  sciatic 
neiu'algia  on  the  right  side.  Uterine  treatment  by  a  now  deceased  well- 
known  gynecologist,  directed,  as  the  lady  said,  to  the  healing  of  an  "  ul- 
ceration "  of  the  neck  of  the  womb,  failed  to  relieve  the  migraine.  Still 
for  years  there  had  been  no  symptoms  j)ointing  to  uterine  disease,  except 
sterility,  she  never  having  conceived  again.  An  examination  revealed  a 
perfectly  healed  bilateral  laceration  of  the  cervix  of  the  thii-d  degree,  with 
rather  well-marked  cicatrix,  the  cervix  being  slightly  attached  by  an  old  ad- 
hesion to  the  right  side.  Fii'm  pressure  on  the  cicatrix  in  the  ujDper  angle 
of  the  right  fissure  at  once  produced  the  sciatica  on  that  side. 

For  the  purjDose  of  trying  the  influence  on  the  hemicrania  of  counter- 
irritation  by  tincture  of  iodine  to  the  cervix,  I  made  several  such  applica- 
tions with  the  result  of  bringing  on  a  violent  attack  of  hemicrania.  With 
a  sedative  object  in  view,  I  applied  the  negative  pole  of  a  galvanic  battery 
by  a  small  button  to  the  right  side  of  the  cervix,  and  the  other  over  the 
abdomen  and  right  hip,  using  six  to  twelve  cells  for  about  half  an  hour. 
As  a  result  of  about  twenty  of  these  sittings,  the  next  menstrual  j)eriod  was 
attended  by  only  a  very  shght  attack  of  hemicrania,  the  next  by  none  at 
all,  and  after  three  months  of  treatment,  during  which  there  had  not  been 
a  single  attack  (for  eighteen  years  she  had  had  at  least  two  or  three  every 
month),  I  first  gradually  diminished  and  then  ceased  the  galvanic  treat- 
ment, and  finally,  in  order  to  secure  a  permanent  result,  excised  the  whole 
cicatrix  from  both  sides  of  the  cervical  rent,  sewed  it  up,  and  obtained 
perfect  union.  Since  then,  nearly  three  years,  the  lady  has  been  free  from 
migraine.  In  this  case  the  result  of  the  local  treatment  (ai^phed  directly 
to  the  spot  whence  the  sciatic  neui-algia  seemed  to  spring)  and  of  the  ex- 
cision of  the  cicatrix,  leave  me  no  room  to  doubt  the  relation  of  cause  and 
effect  between  the  cicatrix  and  the  far  distant  frontal  neuralgia. 

In  another  instance  a  woman,  mother  of  one  child,  was  brought  to  me 
by  her  husband  for  the  pecuhar  reason  that  at  every  coition  she  would  go 
into  a  deep  sleep,  from  which  she  could  be  roused  with  difficulty.  As  this 
phenomenon  was  both  sui-prising  and  disagreeable  to  the  husband,  he 
asked  for  advice.  An  examination  with  the  finger  discovered  a  deep  bi- 
lateral laceration  with  considerable  eversion.  Receiving  no  answer  to  my 
qiiestion,  whether  firm  pressure  in  the  angles  of  the  rent  gave  rise  to  pain, 
I  looked  at  her  face,  and  found  her  fast  asleep  with  eyes  closed  and  regular 


OPERATIOIT    FOR    LACERATION    OF    THE    CERVIX    UTERI.      443 

respiration.  Neither  speaking  to  her  nor  vigorous  shaking  could  arouse 
her.  I  bethought  myself  of  Charcot's  expedient  for  hysterical  paroxysms, 
and  pressing  my  fingers  deep  into  the  left  ovarian  region,  succeeded  in 
eliciting  a  groan,  and  then  making  pressure  on  the  right  side  also,  the 
patient  opened  her  eyes  and  sat  up.  She  was  utterly  unconscious  of  what 
had  occurred.  A  repetition  of  the  examination  was  attended  by  a  return 
of  the  sleep  (which  resembled  catalepsy),  and  the  examination  was  con- 
cluded in  this  state.  An  excision  of  both  cicatricial  plugs  and  union  of  the 
Hps  resulted  in  a  cure,  of  the  permanence  of  which  the  husband  assured 
me,  and  of  which  I  satisfied  myself,  so  far  as  a  digital  examination  was  con- 
cerned. 

In  a  case  of  hemichorea  with  retroversion  and  a  lacerated  cei-vix,  I 
operated  for  Dr.  E.  C.  Seguin,  who  had  vainly  tried  every  means  at  his 
command  to  cure  the  chorea.  I  gave  no  special  hope  of  relief  by  the 
operation,  because  I  could  not  discover  any  relation  between  the  tear  and 
the  neurosis.  Still,  it  being  the  only  pathological  condition  discernible, 
and  replacement  of  the  uterus  and  a  pessary  having  failed  to  improve  her, 
we  concluded  to  try  this  last  resort.  For  some  months  after  the  operation 
there  was  a  very  slight  imiDrovement ;  but,  soon  after  her  return  home,  the 
patient  conceived,  the  chorea  rapidly  disappeared  ;  she  went  to  term  and 
was  safely  delivered,  and  is  now  entirely  well,  with  no  return  of  the  chorea. 

Dr.  K.  Stansbury  Sutton,  of  Pittsburg,  Pa.,  reports  a  case  ("  American 
Gynecological  Transactions,"  vol.  vi.,  1881)  of  catalej^tifoi-m  trance  produced 
by  a  lacerated  cervix,  and  cured  by  the  repair  of  the  latter. 

Now,  if.  neuroses  of  the  kind  described  in  the  first  two  cases  of  mine  and 
that  of  Dr.  Sutton  (my  chorea  case  I  will  exclude,  as  the  possible  curative 
influence  of  pregnancy  must  be  admitted)  can  depend  on  reflex  iiTitation 
from  an  old  cicatrized  cervical  laceration,  and  be  permanently  relieved  by 
the  removal  of  the  irritant  tissue  and  repair  of  the  rent,  who  will  deny  the 
possibility  of  a  neurosis  in  any  portion  of  the  body  being  due  to  the  same 
cause,  or  the  existence  of  the  indication  for  the  same  treatment?  I  do  not 
believe  that  such  cases  are  common,  but  should,  still,  on  the  strength  of 
those  related,  incline  to  look  upon  certain  neuroses  in  women,  no  matter 
how  distant  from  the  pelvis,  as  possibly  symptoms  of  some  uterine  disease, 
which  might  be  a  cervical  laceration,  or  a  displacement,  or  something  else  ; 
and  such  neuroses,  if  occurring  at  the  menstrual  period,  would  probably 
induce  me  to  request  a  vaginal  examination. 

Diagnosis. — "While  the  existence  of  a  laceration  of  the  cervix  may  be 
suspected  from  the  objective  symptoms  above  described,  a  jjositive  diag- 
nosis can  only  be  made  by  a  physical  examination,  which  may  be  conducted 
in  either  of  the  two  usual  ways,  by  the  touch,  or  by  the  eye  through  a  specu- 
lum, either  of  which  will  ordinarily  suffice  for  a  diagnosis.  As  a  rule  it  is 
wise  to  make  use  of  both  methods,  and  to  supplement  the  touch  by  the 
siDCculum. 

By  the  Touch. — A  finger  familiar  ^ith  the  appearance  or  feel  of  a  normal 
cervix  will  readily  detect  the  presence  of  a  laceration.  Even  the  tyro  can- 
not fail  to  recognize  the  dilference  between  the  smooth,  conoid  body  which 


444  GYNECOLOGICAL    OPERATIONS. 

his  reading  has  taught  him  to  represent  the  normal  cervix,  and  the  irreg- 
ular, notched  projection  which  his  finger  encounters  as  it  approaches  the 
upper  portion  of  the  vagina.  In  accordance  with  the  variety  of  the  lacer- 
ation the  finger  finds  one  or  two  lateral  fissures,  or  an  anterior  or  posterior 
one,  varying  in  depth  according  to  the  degree  of  the  tear.  The  torn  lips 
of  the  cervix  may  be  more  or  less  separated  and  hyperplastic.  If  the  rent 
is  of  the  third  degree  and  the  hps  are  completely  everted,  the  finger  will  at 
once  enter  a  shallow  cavity  in  the  centre,  which  is  hounded  on  aU  sides,  but 
chiefly  laterally,  by  a  soft,  velvety,  or  shghtly  gTanular-feeHng  surface, 
which  terminates  m  a  rather  shai-p  border,  the  edge  of  the  normal  os  and 
the  beginning  of  the  vaginal  mucous  membrane  covering  the  outside  of 
the  cervix.  In  extreme  cases  the  cervix  feels  like  a  mushroom  filling  the 
vao-inal  vault,  and  the  examining  finger  may  have  some  diflficulty  in  reach- 
iuo-  the  limits  of  the  expanded  lips,  chiefly  the  posterior,  which  in  such 
cases  extends  as  far  back  as  the  posterior  vaginal  wall.  This  eversion  nat- 
urallv  destroys  the  normal  conicity  of  the  cervix  and,  in  aggravated  cases, 
the  sulcus  between  the  cervix  and  vaginal  vault  may  be  entirely  obliter- 
ated, and  the  surface  of  the  vagina  and  the  everted  lip  form  one  continuous 
line. 

The  finger  can  occasionally  feel  the  dense  cicatrix  in  the  upper  angle 
of  the  rent,  and  firm  pressure  there  will  often  cause  local  and  radiating 
pain  to  the  ovaries  and  other  parts  of  the  pelvis,  sometimes  even  down  the 
thighs.  If  the  everted  lips  are  eroded,  a  digital  examination  usiaally  pro- 
vokes a  discharge  of  blood,  generally  mixed  with  viscid  mucus  from  the 
gaping  cavity. 

Through  the  Speculum. — If  a  lacerated  cervix  is  exposed  through  a 
cylindrical  speculum,  the  lumen  of  the  instrument  wiU  be  occupied  by  a 
bright-red,  raw-looking,  perhaps  bleeding  mass,  which  more  or  less  fills 
the  speculum  according  to  the  diameter  of  the  tube  and  the  cervix,  and  the 
depth  of  the  rent.  In  itself  this  raw  surface  gives  no  evidence  of  its  true 
character,  or  that  it  is  the  result  of  a  laceration  of  the  cervix.  The  eye 
perceives  a  mass  resembling  a  peeled  ripe  tomato,  or  very  ripe  strawberry, 
filling  the  lumen  of  the  speculum ;  friction  with  cotton  on  the  dressing- 
forceps  generally  draws  blood,  and  the  natural  inference  is  that  this  is 
what  our  predecessors  confidingly  called  it,  an  "ulcerated"  cervix.  In- 
deed, I  doubt  not  that  the  "ulceration  of  the  os"  of  the  past  generation 
was  in  by  far  the  larger  majority  of  cases  nothing  but  a  lacerated  cervix 
with  everted  and  eroded  lips.  They  saAV  it  only  through  a  tubular  specu- 
lum, an  instrument  which,  by  its  circular  upward  pressure  when  inserted  to 
its  full  length,  necessarily  separates  the  torn  lips  and  increases  the  erosion, 
thereby  changing  a  comparatively  small  rent  to  one  with  disproportionate 
ectropium  of  endotrachelian  mucous  membrane  ;  they  failed  to  notice  the 
edges  of  the  cervical  hps  and  to  understand  the  true  relation  of  this  raw 
surface,  which  was  not  cervix  at  all,  but  cervical  canal,  and  they  pro- 
nounced the  case  one  of  "  ulceration  "  and  treated  it  accordingly.  We  can ' 
hardly  blame  them,  since  those  practitioners  at  the  present  day  who  still 
use  only  the  cylmdrical  speculmn,  cannot  but  fall  into  the  same  error  of 


OPERATION    FOR    LACERATION    OF    THE    CERVIX    UTERI.      445 

diagnosis.  Indeed,  it  would  be  almost  impossible,  even  for  the  expe- 
rienced modern  gynecologist,  who  is  perfectly  familiar  with  the  peculiar  ap- 
pearance of  a  lacerated  and  everted  cervix,  to  diagnose  this  condition  with 
positive  certainty  through  a  tubular  speculum. 

The  bivalve  speculum  is  far  suj)erior  to  the  tubular  in  affording,  by  the 
wider  separation  of  its  branches,  a  more  complete  view  of  the  cervix  and 
the  vaginal  vault.  It  possesses  in  a  minor  degree  the  disadvantage  of 
sej)arating  the  torn  lips  and  exaggerating  the  degTee  of  laceration.  But 
it  allows  the  sound  borders  of  these  hps  to  be  seen,  and  thus  enables 
the  experienced  eye  to  recognize  the  true  state  of  affairs,  and  the  relations 
which  these  lips  hold  to  each  other.  The  novice,  however,  or  the  pi'ac- 
titioner  familiar  only  with  the  tubular  sj^eculum,  will  probably  still  fail  to 
make  the  correct  diagnosis,  and  will  see  only  a  large  "ulcerated  "  cervix. 

The  Sims  speculum  is  really  the  only  form  of  instrument  through 
which  this  lesion  can  be  properly  diagnosed  and  its  extent  and  siguihcance 
appreciated,  as  well  as  its  surgical  cure  carried  out.  It  is  true  that  many 
German  gynecologists  prefer  and  succeed  veiy  well  with  Simon's  compli- 
cated set  of  vaginal  depressors,  using  them,  as  they  must  be  used,  in  the 
dorsal  position.  But  this  method  requires  more  assistance  in  managing 
the  specula,  and  affords,  it  seems  to  me,  less  space  between  the  thighs  for 
the  operator's  hands.  At  all  events,  we  in  this  country  are  so  used  to 
Sims'  speculum  and  position,  and  feel  so  well  satisfied  with  it,  that  we  do 
not  care  to  exchange  it  for  another. 

The  Sims  not  only  affords  the  fullest  possible  exposure  of  cervix  and 
vagina,  but  it  also  permits  the  cervix  to  be  managed  with  instruments  in 
every  manner  necessary  for  diagnosis  and  treatment.  Now,  how  is  this 
diagnosis  made  ?  The  patient  being  placed  in  Sims'  position,  the  specu- 
lum is  inserted,  and  the  cervix  laid  freely  bare.  The  anterior  vaginal  wall 
is  thoroughly  pressed  down  by  the  depressor,  and  the  largest  separation  of 
the  torn  lips  is  thus  obtained.  The  appearance  of  the  three  degrees  of  lacer- 
ation is  well  shown  in  Figs.  235,  236,  and  237,  drawings  of  which  were  taken 
through  Sims'  speculum.  The  depth  of  the  rent,  as  shown  by  the  relation 
of  its  upper  angle  to  the  vaginal  mucous  membrane,  where  it  is  reflected 
from  the  vaginal  vault  to  the  cervix,  is  now  ascertained  by  hooking  a  te- 
naculum into  the  outer  border  of  each  lip,  or  each  side  of  the  fissure  (Fig. 
237),  and  approximating  them  gently  until  all  the  raw,  deep-red  cervical 
lining  is  rolled  in,  the  lips  are  reinverted,  and  only  a  gTOOve  in  the  pale- 
pink  surface  marks  the  seat  and  extent  of  the  laceration.  The  normal 
form  and  dimension  of  the  cervix  is  thus  re-established,  and  a  safe  gniide 
given  for  the  operator  in  marking  out  his  field  for  the  permanent  restora- 
tion of  the  part. 

It  is  this  approximation  of  the  torn  and  separated  lips,  and  the  momen- 
tary restoration  of  the  integrity  of  the  cervix,  which  is  possible  only 
through  a  speculum  affording  the  freedom  of  movement  for  uterus  and 
hands  given  by  the  Sims. 

This  maneuvre  is  useful  in  another  respect  besides  enabling  us  to  de- 
termine the  depth  of  the  rent :  it  also  shows  us  the  mobiUty  of  the  uterus 


446  GYNECOLOGICAL    OPERATIONS. 

and  of  the  separated  lips,  and  whether  they  can  be  appi'oximated  so  as  to 
simulate  health.  If  this  is  not  the  case,  an  essential  factor  is  wanting  for 
an  operative  cure. 

Any  diminution  in  the  normal  mobility  of  the  uterus,  as  shown  by  trac- 
tion on  the  cervix  in  various  directions  with  the  tenaculum,  would  prob- 
ably counter-indicate  (at  least  for  a  time)  operative  treatment.  In  addi- 
tion to  the  mobility  of  the  separated  lips  and  of  the  whole  uterus,  the 
amount  of  erosion  and  of  hyperplasia  (cystic  and  papillary)  of  the  cervix, 
and  of  discharge  from  the  cervical  canal,  should  be  ascertained  through 
the  speculum,  as  these  conditions  are  of  great  importance  in  deciding  on 
treatment,  duration,  and  prognosis. 

If  in  any  case  there  should  be  doubt  as  to  whether  there  is  a  laceration 
with  highly  everted  lips  and  an  eroded,  ectropionized,  endotrachelian  lin- 
ing, or  whether  the  case  is  merely  one  of  erosion  of  a  flat,  short  cervix,  the 
possibility  of  drawing  together  the  edges  of  the  eroded  surface  with  te- 
nacula  hooked  into  each  side  will  at  once  conclusively  decide  in  favor  of  a 
laceration.  While  it  is  possible  to  draw  the  loose  mucous  membrane  of 
the  vagina  by  main  force  over  a  central  erosion  of  the  cervix,  and  thus 
simulate  the  maneuvre  described  above  as  characteristic  of  a  laceration,  it 
is  not  possible  in  such  a  case  to  apjjroximate  the  sides  of  a  cervix  which 
have  never  been  separated,  and  that  is  what  is  done  in  laceration.  An  er- 
ror can,  therefore,  be  made  only  through  carelessness. 

While  it  is  easy  to  make  a  diagnosis  of  laceration  by  the  touch  or  the 
speculum  alone,  it  is  always  advisable  to  make  use  of  both  methods,  and 
to  follow  the  touch  by  the  Sims.  By  the  touch,  chiefly,  can  we  ascertain 
the  mobilit}'  of  the  uterus,  and  the  condition,  as  regards  previous  inflamma- 
tory processes,  of  the  pelvic  cellular  tissue  and  peritoneum  and  the  ovaries. 
Besides,  the  touch  will  generally  give  a  better,  more  correct  idea  of  the 
depth  of  the  fissure,  since  the  necessary  expansion  of  the  vagina  by  air 
during  a  Sims  examination  often  obliterates  somewhat  the  depth  of  the 
rent.  I  have  frequently  been  surprised  to  see  a  rent,  which,  by  the  touch, 
appeared  very  deep,  look  quite  shallow  through  the  Sims.  But  the  ap- 
proximation of  the  lips  with  tenacula  will  always  reveal  the  precise  state 
of  affairs.  But  I  admit  that  more  than  once,  after  having,  by  the  touch, 
pronounced  a  cervix  sufficiently  torn  to  demand  operation,  I  have  been 
compelled  to  reverse  my  decision  on  seeing  how  comparatively  small  the 
rent  appeared  and  how  healthy  the  tissues  looked  through  the  speculum. 
This  discrepancy  was  probably  due  greatly  to  the  deepening  of  the  fissure 
by  the  pressure  of  the  examining  finger. 

One  other  advantage  of  always  making  a  specular  examination  in  addi- 
tion is,  that  the  exact  site  of  the  original  external  os  and  the  direction  and 
dimension  of  the  cervical  canal  can  be  accurately  mapped  out,  information 
which  is  but  very  superficially  conveyed  by  the  touch  or  the  sound.  This 
point  is  of  supreme  importance  during  the  plastic  operation  for  repair  of 
the  cervix. 

If  the  fissure  is  unilateral,  the  original  seat  of  the  external  os  will  not  be 
the  spot  where  the  rent  appears  the  largest  or  where  the  cervical  canal 


OPERATION"    EOPw    LACERATIOISr    OF    THE    CERVIX    UTERI.      447 


gapes,  but  the  lowest  tijD  of  the  cervix.  A  glance  at  Fig.  234  will  explain  this 
statement.  In  a  bilateral  laceration  of  equal  degree  on  both  sides,  the  exter- 
nal OS  will  always  be  located  at  the  extreme  central  tip  of  the  everted  Hps. 

Differential  Diagnosis. — I  have  already  referred  to  the  prevalent  eiTor  in 
the  past,  and  perhaps  still,  among  some  older  practitioners,  that  the  num- 
erous cases  of  a  raw%  bleeding,  or  freely  secreting  cervix,  are  instances  of 
"ulceration  "  of  that  part.  This  error  was  excusable  before  the  discovery 
of  the  true  character  of  this  apparent  ulcer.  But  now,  when  the  teachings 
of  Emmet  and  his  followers  have  made  plain  to  every  intelligent  and  un- 
prejudiced mind  that,  in  the 
large  majority  of  instances,  a 
lesion  of  j)arturitiou,  a  laceration 
of  the  neck  of  the  womb,  under- 
lies this  so-called  ulcer  ;  when, 
by  the  finger  or  through  a  Sims 
speculum,  the  correctness  of  this 
assertion  can  be  easily  and  in- 
fallibly demonstrated,  nothing 
but  absolute  voluntary  blind- 
ness can  account  for  a  failure  to 
accept  this  fact.  An  ulcer  im- 
plies a  loss  of  substance,  which 
is  not  necessarily  present  in  a 
lacerated  cervix.  Of  course,  a 
sloughing  of  a  portion  of  the 
cer^dx  may  take  jDlace,  and  thus  an  ulcer  be  formed  ;  but  this  is  an  addi- 
tion to  the  original  lesion,  not  a  usual  feature.  The  laceration  is  merely 
a  severing  of  the  cervical  tissues,  which  can  be  restored  to  their  integiity 
by  a  simple  re-attachment  of  their  vivified  edges.  Instead  of  there  being 
a  loss  of  tissue  in  cervical  lacerations,  there  is,  generally,  the  reverse,  the 
papillary  and  follicular  hyperj)lasia  increasing  the  size  of  the  whole  cervix 
and  raising  the  eroded  surface  above  the  surrounding  tissue.  If  this  hy- 
perplasia is  excessive,  the  cervix  may  be  covered  with  a  mass  of  fungous 
granulations  (Fig.  243),  and  the  differential  diagnosis  between  this  benign 
affection,  called  cystic  hyperplasia,  and  epithelioma,  be  possible  only  by 
the  microscope.  Several  such  cases  have  come  under  my  notice,  one  which 
the  accompanying  cut  represents,  another  recently  sent  me  by  the  family 
physician  as  epithelioma,  in  which  the  removal  of  the  fungoid  masses  with 
scissors  and  union  by  sutures  of  the  opposing  edges  of  mucous  membrane, 
resulted  in  a  permanent  cure. 

I  may  mention  that  I  have  seen  at  least  one  similar  case  in  a  nullipara, 
the  excrescence  from  the  lips  of  the  cervix  resembhng  very  much  a 
cock's  comb  (the  cock's  comb  granulation  of  Evory  Kennedy,  "Hahnen- 
kammgeschwiir  "  of  the  Germans),  w4aich  was  cured  by  excision  and  cauter- 
ization with  nitric  acid.  The  condition  Avhich,  by  its  raw,  eroded  appear- 
ance, may  simulate  an  ectropium  accompanying  laceration,  is  a  simjile 
erosion  of  the  vaginal  covering  of  the  cervix,  with  or  without  an  eversion 


-Cystic  and  Papillarv  Hyperplasia  Simulating 
Epithelioma  (P.  F.  M.). 


448  GYNECOLOGICAL    OPEEATIONS. 

of  the  swollen,  puffy  endotraclielian  mucosa  tlirough  the  gaping  os.  This 
couclitiou  occurs  more  frequently  in  virgins  and  nulliparae  than  in  parous 
women,  and  is  generally  the  result  of,  and  accompanied  by,  a  chi'onic 
catarrh  of  the  cervix.  The  constant  viscid  and. somewhat  acrid  discharge 
from  the  cervical  canal  softens  the  epithelium  coveiing  the  cervix,  friction 
against  the  vaginal  walls  or  coition  removes  the  softened  epithelium,  and  a 
raw  surface  appears,  which  discharges  freely  and  bleeds  on  touch.  Soon 
this  raw  surface  becomes  dotted  with  small  elevations,  the  swollen  papillae, 
and  is  now  a  "  granular  "  erosion  ;  or  3'ellow,  translucent  spots  appear  on 
it  here  and  there,  some  elevated,  others  flat,  and  we  have  the  "follicular" 
erosion.  This  erosion  may  occupy  only  one  lip  of  the  cervix,  generally  the 
one  over  which  the  discharge  flows  in  the  existing  position  of  the  uterus  (if 
normal,  the  anterior),  or,  which  is  most  rubbed  against  the  vaginal  wall 
(generally  the  posterior) ;  or  the  erosion  may  be  circular,  and  is  then  con- 
tinuous with  the  puffy  mucous  Hning  of  the  cervical  canal.  But  here  we 
have  no  fissure  and  no  loss  of  substance.  It  is  neither  a  laceration  nor  an 
"ulcer,"  but  merely  an  erosion,  and  the  differential  diagnosis  is  readily 
made  by  a  digital  and  specular  examination  and  a  remembrance  of  the 
distinctive  features  of  each  condition  (see  Figs.  100,  101,  102). 

It  may  be  permissible  to  mention  here  that  there  are  but  four  varieties 
of  true  "  ulcer  "  found  on  the  cervix  uteri :  the  cancerous,  the  syphilitic,  the 
varicose  (rare),  and  that  produced  by  fi'iction  of  a  prolapsed  uterus.  In  all 
of  these  there  is  actual  loss  of  substance. 

A  peculiar  congenital  malformation  of  the  cervix  uteri  has  been  ob- 
served by  Fischl,  of  Prague,  in  a  still-born  infant,  and  I  have  since  seen  one 
case  in  a  virgin  of  sixteen  yeai's  :  The  cervix  presents  a  distinct  bilateral 
cleft,  with  separation  of  the  hps  simulating  so  closely  a  laceration  that,  in 
my  case,  only  the  presence  of  a  tense  hymen  could  con^siuce  me  that  it  was 
not  a  puerperal  lesion.  An  examination  made  with  the  smallest  Sims  spec- 
ulum showed  a  broad,  eroded  cervix,  the  lips  of  which  coiild  be  approxi- 
mated by  tenacula  very  much  as  in  true  laceration.  The  importance  of 
recollecting  the  possibihty  of  a  congenital  malformation  simulating  a 
puerperal  laceration  of  the  cervix,  in  a  case  of  a  supposed  nullipara  where 
the  hymen  happened  to  be  absent,  should  not  be  overlooked,  especially  as 
a  very  distinct  and  well-marked  laceration  may  be  produced  by  an  abor- 
tion even  as  early  as  the  second  month,  which  would  not  leave  the  usual 
traces  of  full-term  delivery  on  the  external  genitals. 

E\-iL  Results  of  Laceeatiox. — The  majority  of  the  pathological  condi- 
tions induced  by  laceration  of  the  cervix  have  already  been  described  under 
Pathology,  and  I  will  merely  re-enumerate  them  :  Subinvolution  of  the  cer- 
vix or  the  whole  uterus  ;  cervical  and  corporeal  endometritis  ;  papillary  and 
cystic  hyperplasia  of  the  cervix  ;  uterine  fungosities  ;  menorrhagia  ;  uterine 
displacements ;  chronic  peri-uterine  cellulitis  and  peritonitis  ;  neuralgia  of 
cervix  ;  chronic  ovaritis  ;  epithelioma.  But  there  are  two  other  conditions 
which,  coming  into  play  only  at  certain  times,  have  not  yet  been  described. 
I  mean  the  incapacity  for  conception,  or  absolute  sterility  ;  and  its  con- 
verse, the  tendency  to  abortion,  or  vii-tual  sterihty. 


OPERATION"  FOR  LACERATION  OF  THE  CERVIX  UTERI.   449 

It  is  a  curious  fact  at  first  sight  that  these  two  conditions,  steriHty  auJ 
the  possibihty  of  conception  (if  not  of  retention  of  the  ovum),  shovild  result 
from  the  same  pathological  process.  On  the  one  hand  the  laceration  for- 
bids conception,  on  the  other  it  permits  it,  or  even  facilitates  it  by  means 
of  the  unusual  gaping  of  the  cervical  canal.  But  the  explanation  is  easy 
when  we  consider  the  subsequent  changes  in  the  cervical  cavity  and  their 
consequences.  The  thick,  semi-purulent  mucus  discharged  by  the  hj-per- 
plastic  glands  in  the  cervical  canal  virtually  jJugs  the  passage  and  prevents 
the  entrance  of  the  spermatozoa,  or  washes  them  away  if  they  have  suc- 
ceeded in  gaining  a  foothold.  Besides,  the  purulent  corporeal  secretion  may 
interfere  with  their  vitality,  and  the  hyperplastic  endometrium  may  oppose 
a  mechanical  barrier  to  the  upward  progress  of  the  spermatozoa,  or  afford 
a  poor  soil  for  the  nidation  of  the  ovum.  Bat,  granting  that  the  cervical 
canal  is  found  free  from  mucus,  as  no  doubt  often  happens,  and  the  other 
obstacles  fail,  conception  takes  2:)lace,  the  ovum  develops,  and  gradually 
expands  the  cavity  of  the  corpus  uteri.  The  absolute  sterility  has  been 
overcome  and  the  woman  is  pregnant !  Now  steps  in  the  laceration  again 
as  a  destroyer  of  her  hopes.  As  the  uterine  cavity  proper  expands,  the  or- 
gan assumes  a  spherical  shape,  with  a  short,  broad,  flattened  cervix  attached 
to  its  lower  segment ;  the  cer\-ical  canal  is  practically  effaced,  the  internal 
OS,  in  lacerations  of  the  third  degree,  is  immediately  continuous  with  and 
contiguous  to  the  vaginal  tube,  and  its  tissues  are  therefore  directly  ex- 
posed to  the  irritation  of  friction  against  the  vaginal  walls,  and  the  injuiy 
so  hable  to  be  inflicted  by  coition.  The  result  of  these  factors  is  that  the 
internal  os  gradually  opens,  a  slight  hemorrhage  from  the  endometrium 
takes  place,  uterine  contraction  sets  in,  and  the  o^^m  is  expelled.  This 
train  of  events  may  occur  again  and  again,  with  each  succeeding  miscar- 
riage the  patient  becoming  more  and  more  an  invalid  and  less  capable  of 
reproduction. 

While  these  results  frequently  follow  lacerations,  there  are  numerous 
instances  where  women  with  large  rents  not  only  conceive  readily  but  cany 
their  children  to  term,  are  easily  deUvered,  and  make  good  recoveries. 
These  seeming  contradictions  belong  as  yet  to  the  mysteries  of  nature,  to- 
gether with  many  of  the  hidden  causes  of  sterility,  the  determination  of 
the  sex,  etc. 

Another  condition  which  is  frequently  present  as  a  result  of  laceration, 
is  dyspareunia,  the  reason  for  which  will  be  readily  attributed  to  the  various 
pathological  changes  in  the  parts  already  described.  Painful  coition  will 
naturally  increase  the  chances  against  conception,  since  that  act  will  prob- 
ably be  less  frequently  and  less  perfectly  performed. 

Prognosis. — Untreated,  many  cases  of  laceration  gradually  cicatrize  over, 
and  when  the  patient  arrives  at  the  menopause  and  sexual  activity  ceases, 
the  uterus  and  ovaries  atrophy,  and  the  symptoms  which  the  patient  has 
borne  so  many  years  diminish  and  ultimately  disaj^pear.  The  same  atro- 
phy may  take  place  at  the  menopause  even  when  the  lacerated  cervix  has 
remained  raw,  and  the  shrinking  of  the  cervix  may  bring  about  the  heahng 
of  the  erosion.  But  often  the  latter  may  persist  for  yeai's  after  the  -chmac- 
29 


450  GYNECOLOGICAL    OPERATIOlSrS. 

teric  and  annoy  the  woman  by  the  discharge.  Very  commonly  the  hyper- 
emia maintained  by  a  deep  laceration  with  eversion  and  erosion  will  pro- 
long the  menstrual  flow,  and  if  hyperjDlastic  endometritis  has  followed  the 
lesion,  the  menopause  may  be  postponed  several  years,  and  not  come  on 
until  the  morbid  condition  has  been  removed  by  appropriate  treatment. 
I  have  thus  seen  menstruation  continue,  to  a  profuse  degree  even,  beyond 
the  fiftieth  year,  and  require  curetting  of  the  endometrium  and  repair  of 
the  laceration  before  it  could  be  arrested  and  the  menopause  inaugurated. 
Thus  even  the  usual  period  for  this  physiological  event  may  not  suffice  to 
check  the  evil  results  of  the  lesion,  and  the  suffering  may  be  prolonged 
even  beyond  the  time  for  sexual  rest.  It  is  certain,  if  the  laceration  occurs 
early  in  reproductive  life  and '  its  degree  and  symptoms  are  marked,  that 
the  latter  are  more  than  likely  to  continue  without  marked  abatement  until 
the  time  for  the  menopause  anives,  unless  at  least  palliative  treatment  is 
employed.  This  is  the  prospect  which  a  conscientious  and  experienced 
physician  must  offer  to  a  patient  who  asks  him  what  her  chances  are  if 
the  condition  is  not  treated  in  any  way.  And  he  has  no  right  to  conceal 
the  possibility  of  an  eventual  malignant  degeneration  of  the  cei-vix. 

It  is  quite  true,  however,  that  palliative  treatment  by  caustics  and  as- 
tringents, by  hot  injections  and  glycerine  tampons,  will  after  a  while  pro- 
duce at  least  temporary  relief,  and  I  have  seen  cases,  which  at  first  sight 
seemed  imperatively  to  demand  an  operation,  improve  so  much  after  sev- 
eral months  of  the  above  treatment  as  to  oblige  me  to  alter  my  previously 
expressed  opinion  and  pronounce  the  oj)eration  now  unnecessary.  But  we 
should  not  forget  that  such  relief  is  more  than  Ukely  to  be  merely  tempo- 
rary, and  that  the  symptoms  may  soon  return  in  all  their  original  intensity. 

There  can  be  no  question,  so  far  as  my  experience  goes,  that  a  woman 
with  a  large  ununited  laceration  of  the  cervix,  which  jDroduces  the  majority 
of  the  symptoms  already  enumerated,  remains  moi'e  or  less  an  invalid  so 
long  as  the  rent  is  not  radically  cured  by  operation,  or  until  the  meno- 
pause atrophies  her  sexual  organs  in  the  natural  order  of  events.  Let 
those  who  scoff  at  the  importance  of  intelligently  and  thoroughly  treating 
this  lesion,  read  and  reflect ! 

That  many  women  spontaneously  recover  from  the  laceration,  or  seem 
little  affected  by  its  persistence,  or  conceive  and  bear  children  easily  and 
naturally,  and  never  even  know  that  they  have  such  an  injury,  is  merely  an 
example  of  the  old  saying,  that  "  the  exception  proves  the  rule." 

SiGNrFic.\NCE.— The  existence  of  rents  of  the  cervix  as  the  result  of  partu- 
rition was  known  many  years  ago ;  Sir  James  Simpson  speaks  of  them  in 
1851  ;  Gardner,  of  New  York,  in  his  book  on  "  Sterility "  (1856),  gives 
illustrations  of  the  lesion,  and  attributes  to  it  "  ulceration  "  of  the  cervix, 
catarrh,  sterility,  and  abortion  ;  and  Professor  Koser,  of  Marburg,  in  1861, 
wrote  of  it  under  the  name  of  "  cervical  ectropium."  Fallen,  of  St.  Louis, 
in  1867,  even  sewed  with  silver  wire  a  deep  fissure  of  the  cervix  immediately 
after  its  occurrence  (St.  Louis  Medical  Journal,  May,  1868).  But  with 
these  few  authors  the  history  of  the  lesion  is  complete  until  1869,  when 
Thomas  Addis  Emmet  first  pubHshed  {American  Journal  of  Obstetrics,  Feb- 


OPERATIOIS'    FOE    LACERATION    OF    THE    CERVIX    UTERI.      451 

ruary,  1869)  the  results  of  his  experience  of  a  series  of  years,  and  promul- 
gated what  was  destined  to  be  one  of  the  gi-eatest  medical  achievements 
of  the  century.  He  it  was  who  first  recognized  the  jjathological  significance, 
as  a  prime  factor  in  the  production  of  uterine  disease,  of  this  hitherto 
almost  unnoticed  injury.  He  it  was  who  pointed  out  that  many  local  and 
even  distant  symptoms  depend  on  this  affection  and  its  various  secjuelfe  ; 
and  by  demonstrating  how  the  raw  surface  of  the  old  "  ulceration  "  could 
be  rolled  into  the  cervical  canal  and  made  to  disappear  by  simjoly  approxi- 
mating the  outer  edges  of  the  raw  surface,  at  once  showed  the  character 
of  the  "ulcer"  and  the  method  of  curing  it.  On  this  recognition  of  the 
true  character  of  the  condition  depends  the  discovery  of  the  radical  opera- 
tion for  its  cure,  now  universally  known  by  the  name  of  its  inventor. 

Since  then,  the  operation  has  become,  one  might  say,  almost  fashion- 
able, and  numerous  operators  have  added  their  names  to  the  small  Hst  of 
writers  who  preceded  Emmet.  While  many  of  these  contributions  were 
mere  reports  of  operations  \vithout  any  scientific  value,  a  fair  number  of 
exceedingly  valuable  articles  have  been  written,  partly  on  the  pathology  of 
the  lesion  in  its  later  stages  (Ruge  and  Veit,  Olshausen,  Eokitansky, 
Breisky),  partly  on  its  results  and  treatment  (Goodell,  Spiegelberg,  Nieber- 
ding,  Van  de  Warker,  Wyhe,  Kaltenbach,  Lee,  Munde,  Schroeder),  and 
the  American  text-books  and  several  English  and  German  works  have  in- 
cluded the  subject  among  the  accepted  diseases  of  the  uterus.  Of  the 
American  books,  Emmet  and  Thomas  ;  of  the  English,  Hart  and  Barbour  ; 
of  the  German,  Hegar  and  Kaltenbach,  have  each  devoted  chapters  to  the 
subject.  The  French  seem  as  yet  not  to  have  made  up  their  minds  whether 
the  lesion  is  worthy  of  their  notice,  for  the  author  of  their  best  text-book, 
Courty,  has  omitted  all  mention  of  it  in  his  last  edition  (1883).  It  is  true, 
a  gi-aduation  thesis  was  written  on  it  by  Desvernine,  of  Paris,  in  1879,  but 
it  was  merely  a  very  imperfect  compilation  of  the  articles  of  prerious 
authors. 

The  significance  of  cervical  laceration  as  a  factor  of  uterine  disease  is 
now  universally  accepted  by  advanced  gynecologists  all  over  the  world. 
Here  and  there,  some  of  our  conservative  brethren  of  the  older  school  of 
"  medical  gynecology  "  still  hold  aloof  and  affect  to  doubt  the  great  im- 
portance of  this  lesion  and  the  necessity  for  its  operative  cure  ;  but  they 
are  in  the  minority,  and  as  the  excessive  zeal  in  favor  of  the  operation 
gradually  abates,  and  it  is  confined  to  proper  limits,  I  doubt  not  that  its 
opponents  will  admit  its  necessity  and  join  the  majority.  We  seem  in  a 
fair  way  to  reach  this  point,  at  the  present  day. 

There  is  no  question  that  the  importance  of  the  lesion  has  been  gi'eatly 
exaggerated  in  the  past  few  years,  so  that  ecery  laceration,  no  matter  how 
trivial,  was  at  once  suspected  of  dire  consequences  and  was  accused  of 
being  the  author  of  all  sorts  of  mysterious  symptoms.  And,  naturally, 
the  operation  was  proportionately  overdone.  But  calmer  judgment  has 
led  us  to  select  our  cases  more  carefully,  and  those  of  us  nowadays  who 
try  to  treat  our  patients  intelUgently  and  conscientiously  and  to  avoid 
"  hobbies,"  so  far  as  our  hghts  allow,  have  come  to  the  conclusion,  as  a  re- 


452  GYNECOLOGICAL    OPEEATIOlsrS. 

suit  of  experience  and  deliberation,  tliat  the  significance  of  a  cervical  rent  as 
a  cause  of  uterine  disease  lies  not  in  the  existence  of  the  rent  itself,  but  solely 
in  the  symptoms  lohich  it  produces,  and  in  the  direct  influence  which  can  he 
traced  to  it  as  the  prime  factor  in  the  p)roduction  or  maintenance  of  some 
pathological  condition  or  functional  derangement  in  the  pelvic  organs  or  else- 
where in  the  body. 

What  special  conditions  of,  or  changes  in,  the  cervix  produce  such 
pathological  results,  whether  it  be  the  "cicatricial  plug"  or  the  hyper- 
plasia, cystic  or  papillary,  of  the  cervix,  or  the  cervical  catarrh,  or  the 
aversion  and  erosion  of  the  lips,  that,  the  gynecologist  must  seek  to  deter- 
mine in  each  individual  case,  and  according  to  his  conclusion  decide  as  to 
the  special  significance  of  the  rent,  and  the  necessity  for  its  treatment. 
But  if  careful  examination  fails  to  trace  any  relation  between  the  cervical 
lesion  and  the  objective  signs,  common-sense  will  lead  us  to  seek  else- 
where than  in  the  cervix  for  the  primary  cause. 

Thus  it  may  happen  (although  rarely)  that  a  deep  laceration,  with  all 
the  tissue-changes  in  the  cervix  described  under  Varieties,  produces  no  lo- 
cal or  general  symptoms  whatever  ;  and,  on  the  other  hand,  that  to  a  com- 
paratively shallow,  cicatrized  fissure,  can  be  clearly  traced  an  ovarian,  sci- 
atic, or  supra-orbital  neuralgia.  It  is  the  presence  of  this  relation  between 
cause  and  efiect,  then,  which  constitutes  the  significance  of  the  cervical 
lesion,  not  its  mere  existence.  If  this  relation  be  borne  in  mind,  haphaz- 
ard diagnoses  and  unnecessary  operations  will  not  be  made. 

For  the  detailed  description  of  the  complications  which  may  give  sig- 
nificance to  an  otherwise  trivial  rent,  I  refer  the  reader  to  the  section  on 
Varieties  and  Degrees  of  Laceration. 

From  my  experience,  which  now  extends  over  twelve  years  since  I  first 
saw  Emmet  operate  for  this  lesion,  and  comprises  a  material  of  six  hun- 
dred and  twelve  carefully  recorded  cases  of  appreciable  lacerations  of  aU 
degi-ees,  I  have  come  to  the  general  conclusion  that,  of  aU  the  women  who 
have  a  lacerated  cervix  during  confinement,  one-half,  or  fifty  per  cent, 
sufier  no  inconvenience  whatever  from  the  injury,  either  because  it  was 
slight,  healed  spontaneously,  or  because  involution  was  so  complete  as  to 
reduce  the  originally  deep  rent  to  a  comparatively  trivial  nick. 

Of  the  remaining  fifty  per  cent.,  one-half  (or  twenty-five  per  cent,  of 
the  whole  number)  for  a  time  present  some  of  the  symptoms  already  de- 
scribed, then  gradually  recover  spontaneously,  or  require  palliative  local 
treatment  before  they  are  relieved  and  the  injury  is  reduced  to  a  dormant 
state  ;  of  the  stiU  remaining  twenty-five  per  cent.,  one-half  may  be  curable 
(that  is,  may  be  relieved  of  their  symptoms)  by  appropriate  palliative  treat- 
ment, but  will  eventually  require  the  radical  operation  for  a  permanent 
cure  ;  and  the  last  half,  or  twelve  and  a  half  per  cent,  of  the  whole  num- 
ber, are  absolutely  incurable  otherwise  than  by  the  radical  operation. 

It  thus  appears  that  I  consider  only  one-half  of  all  the  lacerations  of  the 
cer\ix  which  occm-  as  producing  and  requiring  treatment  of  any  kind,  and 
of  these  but  one-quarter,  or  one-eighth  of  all  lacerations,  as  absolutely  re- 
qun-mg  Emmet's  operation.     Surely  I  cannot  be  reproached  with  being 


OPERATION    FOR    LACERATION    OF    THE    CERVIX    UTERI.      453 

an  advocate  either  of  too  universal  pathological  significance,  or  of  uncon- 
ditional operative  treatment,  of  this  lesion. 

Indications  for  Local  Treatment. — The  indications  calling  for  local 
treatment  of  any  kind  to  a  lacerated  cervix  are  regulated  entii'ely  by  the 
significance  of  the  lesion  ah  shown  by  the  symptoms  directly  depending  on 
it.  Such  symptoms  may  be  rational  or  objective,  and  may  depend  on  any 
or  all  of  the  pathological  conditions  following  the  injury,  which  have  al- 
ready been  described.  As  a  general  and  safe  rule,  it  may  be  assumed  that 
any  of  the  tissue-changes  described  as  occurring  in  the  cervix  after  a  lacer- 
ation (erosion,  cervical  catarrh,  cystic  and  papillary  hypei'plasia,  passive 
congestion)  produce  symj^toms  of  sufficient  importance  to  require  treat- 
ment ;  and  the  same  applies  to  the  "cicatricial  plug,"  if  a  reflex  neurosis 
can  be  traced  to  it. 

Treatment. ^ — The  nature,  frequency,  and  duration  of  the  treatment  de- 
pend on  the  depth  of  the  rent,  on  the  complications  which  may  or  may 
not  attend  it,  on  the  absence  of  counter-indications  to  certain  therapeutic 
measures,  and  on  the  toleration  of  the  patient.  Accordingly,  as  it  is  in- 
tended merely  to  relieve  symptoms  and  secure  temporary  benefit,  or  a  per- 
manent cure  is  desired,  it  will  be  palliative  or  radical. 

Palliatim  Treatment. — By  palliative  treatment  are  understood  all  the 
remedies  which  tend  to  relieve  the  local  pathological  conditions  in  the  cer- 
vix, always  excepting  the  laceration  itself.  Thus,  by  it  the  hyperemia  of 
the  cervix  is  diminished,  the  cervical  catarrh  is  cured  or  held  under  con- 
trol, the  cystic  and  papillary  hyperplasia  and  the  erosion  of  the  everted 
lips  are  cured,  the  cicatrix  is  softened  and  reduced,  and  thereby  the  reflex 
neuroses  are  relieved  ;  and  secondarily,  the  subinvolution  and  hypei-plasia 
of  the  whole  uterus,  the  chronic  ovarian  congestion,  and  pelvic  cellulitis 
and  lymphangitis,  are  all  benefited  and,  perhaps,  entirely  cured.  And  in 
addition,  the  displacement  of  the  uterus,  the  relaxation  and  prolapse  of 
the  vaginal  wall,  and  the  chronic  vaginal  leucorrhea,  are  relieved.  Who  can 
say,  then,  that  palliative  treatment,  which  does  all  this,  is  useless  ?  But,  ad- 
mitting all  this  benefit,  we  must  still  recognize  the  undoubted  fact  that  no 
palliative  treatment  will  heal  the  laceration  and  restore  the  cervix  to  its 
j)re-puerperal  integrity,  and  that,  so  long  as  the  rent  exists,  all  improve- 
ment is  usually  but  temporary. 

The  remedial  applications  usually  employed  in  the  course  of  this  palli- 
ative treatment  are  the  following  : 

1.  Passive,  chronic  hyperemia  of  the  cervix  and  pelvic  organs  is  treated 
by  daily  injections  of  hot  water  into  the  vagina,  in  the  recumbent  position, 
according  to  the  rules  given  in  the  section  on  Medicinal  Applications  to  the 
Vagina.  Further,  by  occasional  scarification  of  the  cerAix,  about  once  a 
•week  ;  by  painting  it  with  simple  tincture  of  iodine  twice  a  week,  and  by 
inserting,  after  each  application,  or  oftener,  one  or  more  tampons  soaked 
in  a  solution  of  alum  or  tannin  in  glycerine,  which  are  to  be  retained 
until  the  next  morning,  their  removal  being  followed  by  a  hot  vagintxl 
douche. 

2.  The  cervical  catarrh  will  probably  requu-e  the  removal  of  the  hyper- 


454  GYJSTECOLOGICAL    OPERATIONS. 

plastic  glands  by  the  shai-p  curette  before  benefit  can  be  expected  from  a 
caustic  or  alterative  application.  In  very  severe  cases,  the  pure  nitric  acid 
•will  do  the  most  effectual  work,  to  be  followed  by  iodized  phenol,  tincture  of 
iodine,  solution  of  the  nitrate  of  silver,  or  a  similar  agent. 

3.  The  cystic  hyperplasia  is  easily  controlled  by  puncturing  each  Na- 
bothian  follicle  Avith  the  scarificator,  and  immediately  swabbing  the  cervix 
with  tincture  of  iodine  to  produce  obliteration  of  the  follicles.  The  papil- 
lary hj-pei-plasia  is  treated  by  scraping  off  the  enlarged  papillae  (granula- 
tions) with  the  sharj)  curette,  or  trimming  them  off  with  fine  curved  scissors, 
until  the  raw  surface  is  jDerfectly  smooth.  The  treatment  directed  to  the 
cervical  catan'h  and  the  erosion  will  prevent  their  re-formation. 

4.  The  erosion  can  be  healed  by  painting  it  with  the  solution  of  the  ni- 
trate of  silver  (  3  j-,  or  less,  to  3  j.),  or  touching  it  with  nitric  acid,  chromic 
acid,  etc.,  and  when  the  slough  has  separated,  blowing  finely  powdered  iodo- 
form, or  iodoform  and  tannin,  equal  parts,  on  it,  and  placing  a  tannin  or 
vaseline  tampon  against  it. 

5.  The  cicatrix  may  be  reduced  in  density  and  firmness  by  the  same 
treatment  as  that  described  in  Section  1,  minus  the  scarification,  and  the 
congested  ovary  will  yield  to  similar  measures. 

6.  The  chi-onic  pelvic  celluhtis  and  lymphangitis  is  benefited  by  paint- 
ing the  whole  vaginal  vault,  as  well  as  the  cervix,  with  tinctm-e  of  iodine, 
also  by  the  hot  douches  and  glycei-ine  tampons,  and,  fui-ther,  by  a  system- 
atic course  of  tamponade  of  the  vagina,  which  will  also  be  found  very 
useful  to  relieve  congestion  and  displacement  of  the  uterus. 

7.  The  constant  astringent  tamponade  of  the  vagina  contracts  and 
strengthens  that  canal  and  checks  the  leucorrhea ;  and 

8.  The  uterus  may  be  prevented  from  resuming  its  displaced  position 
by  a  proper  pessary,  as  soon  as  the  improvement  of  the  cervix  allows  the  ces- 
sation of  the  local  applications. 

As  will  have  been  noticed,  several  effects  are  produced  by  one  or  the 
other  of  these  remedies,  which  enables  us,  for  instance  with  iodine  and 
hot  water,  to  simultaneously  reduce  congestion,  promote  absorption  of 
hypei-plastic  or  cicatricial  tissue,  and  exert  a  heahng  influence  on  an 
erosion,  and  thus  save  time  and  treatment. 

As  a  i-ule,  the  stronger  applications  should  not  be  made  oftener  than 
twice  a  week ;  the  glycerine  and  astringent  tampons  may  be  used  eveiy 
day,  if  convenient  to  the  patient. 

For  the  details  of  these  applications,  and  other  agents,  I  refer  the  stu- 
dent to  the  chapters  on  Applications  to  the  Cervix  and  Vagina. 

The  length  of  time  required  to  achieve  a  satisfactoiy  result  by  the 
above-mentioned  treatment  varies  very  much  in  proporiion  to  the  intensity 
of  the  complications.  If  there  is  merely  a  laceration  with  eversion  and 
superficial  erosion,  and  no  complications  exist,  no  preparatory  treatment 
whatever  is  required,  and  the  rent  may  be  sewed  at  once.  Or,  if  the  case 
IS  an  old-standing  one,  and  the  complications  are  numerous  and  severe, 
several  months  may  be  required  to  put  the  cemx  and  its  adnexa  in  a 
Buxtable  condition  to  offer  a  good  prospect  for   a   successful   operation. 


OPERATION  FOR  LACERATION"  OF  THE  CERVIX  UTERI.   455 

As  a  rule,  ordinary  lacerations  can  be  prepared  for  operation  during  one 
intermenstrual  period,  so  that  trachelorrhaphy  can  be  safely  jDerfomied  a 
few  days  after  the  next  menstrual  period. 

In  some  (exceptional)  cases  the  operation  may  be  indicated  before  all 
complications  have  been  entii-ely  removed.  Thus,  the  follicles  and  gi-an- 
ulations  may  be  so  numerous,  or  may  return  so  rapidly,  that  only  their 
complete  removal  by  a  cutting  operation  will  prevent  their  reappearance ; 
the  proper  plan  is  then  to  excise  them  thoroughly  during  the  plastic  opera- 
tion. Or,  the  cervix  itself  is  in  good  condition  for  operation,  but  there  are 
still  remains  of  chronic  plastic  exudation  in  the  jDarametrau  cellular  tissue, 
or  the  ovaries  are  still  engorged  and  tender  ;  here  it  is  futile  to  defer  clos- 
ing the  laceration,  the  very  persistence  of  which  perpetuates  the  adjacent 
disturbance,  if  the  operation  can  be  done  with  a  fair  degi-ee  of  safety.  In 
deciding  upon  the  operation,  under  these  particular  circumstances,  which 
are  usually,  and  properly,  looked  u^Don  as  counter-indications,  the  utmost 
care  should  be  observed  to  eliminate  the  possibility  of  re-exciting  the  in- 
flammation, which  has  now  happily  become  "chronic,"  by  testing  the 
susceptibility  of  the  pelric  cellular  tissue  and  the  ovaries  with  measures 
likely  to  irritate  them,  such  as  gentle  traction  on  the  cervix,  approximat- 
ing the  torn  lips  by  tenacula  or  wire  sutures,  etc.  Only  when  such  mild 
manipulations,  practised  for  a  week  or  two,  fail  to  joi'oduce  reaction,  can 
the  operation  be  considered  safe.  And,  during  the  operation,  extraordinary 
care  should  be  exercised  to  avoid  forcible  traction  on  the  uterus. 

An  excellent  preparatory  measure,  which  has  done  me  good  service  in 
several  cases,  is  the  ajDproximation  of  the  strongly  everted  lips  of  a  hyper- 
plastic cervix  by  a  couple  of  silver  wire  sutures  which  are  twisted  more  or 
less  tightly,  cut  short,  and  allowed  to  remain  while  the  patient  goes  about 
for  one  or  two  weeks  before  the  operation.  The  sutures  may  be  intro- 
duced in  the  operator's  office,  if  the  patient  is  willing  to  stand  the  mod- 
erate pain,  one  being  passed  on  each  side  of  the  prospective  external  os. 
Their  effect  is  not  only  to  approximate  the  lips  of  the  cervix  and  lessen 
tension  on  the  stitches  after  the  actual  operation,  but  to  produce  a  de- 
crease in  size  of  the  lips  by  absorption  of  hi^-perplastic  tissue.  These  pre- 
paratory, tentative  sutures  were  of  great  service  to  me  in  a  case  of  extensive 
laceration  and  excessive  eversion,  where  an  old  chronic  peritonitis  not  only 
complicated  trachelorrhaphy  but  also  rendered  the  approximation  of  the 
lips  difl&cult.  After  the  patient  had  worn  the  temporary  sutures  without 
inconvenience  for  two  weeks,  it  was  a  matter  of  but  little  risk  and  difficulty 
to  pare  the  edges  and  insert  the  permanent  stitches,  the  result  being  a 
complete  success. 

In  advocating  active  operative  interference  in  certain  cases  of  compli- 
cation with  old,  inactive  pelvic  exudations,  I  am  well  aware  that  I  am 
treading  upon  dangerous  ground  and  opening  the  door  to  improper  and 
meddlesome  surgery.  I  must  therefore  repeat  the  caution,  to  choose  such 
cases  with  the  utmost  care,  and  to  avoid  all  traction  on  the  cervix  during 
the  operation. 

If  the  rent  be  a  small  cue,  the  eversion  and  erosion  slight,  the  cen-ical 


4,oQ  GYNECOLOGICAL    OPERATION'S. 

catan-h  trifling,  and  the  "cicatricial  plug"  superficial,  such  palliative  treat- 
ment as  I  have  described  may  in  the  course  of  a  month  or  two  produce  so 
much  local  improvement  that  no  further  treatment  is  required.  I  have 
thus  seen  an  angry-looking  rent,  which  appeared  quite  large  enough  to  call 
for  a  plastic  operation,  gradually  assume  a  pale  color,  the  raw  surface  di- 
minish in  extent,  the  lurid  tint  of  the  mucous  membrane  change  to  a 
healthy  pink,  and  the  originally  formidable  tear  dwindle  to  an  insignificant 
nick,  which  it  would  be  absurd  to  deem  worthy  of  an  "  operation."  In  ner- 
vous, timorous  patients  it  is  well  to  remember  this  not  improbable  termi- 
nation, and  to  give  them  the  chance  of  escaping  the  much-dreaded  opera- 
tion. But  they  should  be  informed  of  the  temporary  nature  of  such  relief, 
in  order  that  no  blame  may  be  eventually  cast  on  the  physician  for  his 
failure  to  insist  on  a  radical  cure. 

The  radical  treatment  of  a  lacerated  cervix,  with  or  without  complica- 
tions, consists  solely  in  paring  the  edges  of  the  rent  and  approximating 
them  by  sutures  until  nature  has  united  the  raw  surfaces  permanently. 
Only  m  this  manner  can  a  rent  be  cured,  or  the  everted  and  eroded  sur- 
faces of  the  torn  lips  be  restored  to  health  ;  not  by  the  hot  iron,  the  stick 
of  nitrate  of  silver,  or  any  other  caustic  or  remedy.  To  glaze  over  a  raw 
wound  with  a  cicatricial  film  is  merely  to  hide  the  injur}',  not  to  cure  it. 

It  is  this  operation,  which  owes  its  oiigin  to  the  genius  of  Emmet,  and 
■which  is  known  as  "Emmet's  operation,"  or  by  the  somewhat  ponderous 
name  of  "  hystero-trachelorrhajDhy." 

Indications  foe  Teacheloerhapht. 

It  is  a  difficult  matter  to  lay  down  a  strict  indication  for  the  radical 
operation  of  a  lacerated  cervix.  Each  case  brings  with  it  its  own  indica- 
tion for  or  against  the  operation,  and  the  special  predilection  of  the  gyne- 
cologist will  go  far  toward  deciding  him  to  see  in  a  certain  case  the  neces- 
sity for  a  radical  measure,  or  the  possibility  of  relieving  the  symptoms  by 
paUiative  treatment.  Thus  some  gynecologists  have  seen  cases  by  the  hun- 
dred, which,  in  their  opinion,  demanded  trachelorrhaphy  (at  least  the  num- 
ber of  operations  reported  by  them  reach  that  figure)  ;  and  others  of  equal 
intelligence,  prominence,  and  practical  opportunities  have  scarcely  ever 
performed  the  operation.  I  know  of  two  si^ecialists,  both  older  men  and 
bold  operators,  who  have  never  done  trachelon-haphy,  because  they  have 
never  seen  a  case  which  could  not  be  cured  by  other  treatment  (sic .') ; 
it  is  true,  one  of  these  gentlemen  thinks  he  cures  such  cases  by  amputating 
the  torn  cervix,  and  the  other  claims  to  secure  equally  good  results  by  the 
systematic  tamponade  of  the  vagina.  Of  course,  neither  of  them  cures  the 
laceration  ;  the  first  merely  substitutes  a  flat  raw  surface,  which  he  cannot 
well  cover,  for  two  eroded  lips,  evidently  a  veiy  illogical  proceeding; 
while  the  other,  with  more  reason,  temporarily  relieves  the  symptoms  by 
diminishing  pelvic  h}-peremia. 

Obriously,  to  these  gentlemen,  and  others  of  like  views,  an  indication 
for  tracheloiThaphy  does  not  exist.     As  usual,  the  proper  course  lies  in  the 


IlSTDICATIOlSrS    FOR    TRACHELORRHAPHY. 


457 


middle,  and  the  best  general  indication  which  I  can  formulate  for  tliis  opera- 
tion is  similar  to  the  conclusion  given  when  speaking  of  tlie  significance  of 
the  lesion,  viz.  :  The  mere  existence  of  a  laceration  of  the  cervix  does  not  call 
for  the  radical  operation  ;  the  indication  for  that  measure  depends  entirely  on 
the  depth  of  the  rent,  on  the  degree  of  eversion  and  the  amount  of  erosion  and 
hyperplasia  of  the  torn  lips,  on  the  intensity  of  the  symptoms  unguesticnably 
or  probably  dej^ending  on  it,  and  on  the  improbability  of  these  symp)toms  being 
permanently  cured  by  other  than  radical  treatment. 

Thus,  as  a  rule,  every  laceration  of  the  third  degi'ee  ;  every  laceration 
with  largely  everted  and  eroded  lips,  ^\-ith  hyper2:)lastic  papillae  and  follicles, 
with  gaping  and  freely  discharging  cervical  canal ;  every  laceration  of  a 
large  subinvoluted  or  hyperplastic  uter- 
us ;  every  laceration  with  consequent 
hyperplastic  hemorrhagic  endometritis; 
every  laceration  with  corresponding 
congested  ovary  or  ovaries — should  be 
operated  on,  and  permanently  cured, 
in  order  that  not  only  the  lesion  itself, 
but  its  resultant  pathological  condi- 
tions, may  be  removed.  Further,  every 
laceration,  whether  completely  cica- 
trized over  or  not,  in  which  the  cica- 
tricial tissue  in  the  rent  seems,  on  care- 
ful observation,  to  be  the  cause  of  cer- 
tain reflex  neuroses  in  the  pelvis  or 
remote  parts  of  the  body  ;  every  laceration  in  which  the  glazed-over  sur- 
face breaks  open  at  irregular  intervals  and  annoys  the  patient  by  a  bloody 
discharge  (see  Fig.  244)  ;  every  laceration  in  a  woman  whose  mother  or 
near  blood-relation  died  of  malignant  disease — should  be  subjected  to  the 
radical  operation.  The  last-named  indication,  of  course,  is  but  a  precau- 
tionary one. 

Finall}',  if  the  operation  of  perineoiThaphy  is  to  be  performed,  and  a 
slight  laceration  of  the  cervix  with  moderate  ectropium  is  also  present,  the 
question  arises  whether  it  is  not  best  to  close  the  cervical  rent  first,  before 
placing  it  more  or  less  out  of  easy  reach.  I  have  several  times  done  the 
cervix  operation  first,  and  then  the  perineum  at  the  same  sitting,  chiefly 
because  I  did  not  feel  easy  in  leaving  even  a  slight  rent  unhealed  with  a 
restored  perineum.  Should  the  cervical  tear  afterward  give  her  trouble, 
she  would  naturally  feel  that  it  ought  to  have  been  repaired  at  the  time  the 
one  operation  was  done. 

In  my  article  in  the  January,  1879,  number  of  the  Journal  of  Obstetrics, 
on  the  "Indications  for  Hystero-trachelorrhaphy,"  I  specified  a  few  indi- 
cations for  the  ojDeration  which  I  will  briefly  enumerate  here  as  additions 
to  or  modifications  of  those  already  mentioned  :  1.  Shght  lacerations  with 
persistent  profuse  cervical  leucorrhea.  2.  Slight  lacerations  in  subinvoluted 
or  hyperplastic  uteri,  where  trachelorrhaphy  is  expected  rather  to  reduce 
the  size  of  the  uterus  than  merely  to  cure  the  rent      3.  H^i^ei-plastic 


Fig.  244. — Bilateral  Laceration  with  Eversion, 
Third  Degree,  nearly  Cicatrized.  The  two  Tipper 
corners  show  fresh  breaking  down  of  cicatrix 
(P.  F.  M.). 


458  GYNECOLOOICAL    OPERATIOl^S. 

or  cystic  ectropium  of  one  lip  ;  here  the  enlarged  lip  is  simply  excised, 
and  the  raw  edges  are  brought  together  by  sutures.  4.  Laceration  of 
the  cervical  wall,  of  greater  or  lesser  depth,  not  extending  to  or  through 
the  lips  of  the  os  ;  the  result  is  a  gaping  os  and  a  dilated,  paralyzed  cervix  ; 
by  sHtting  the  lips  bilateraUy  up  to  the  vaginal  vault,  trimming  off  diseased 
mucous  inembrane,  and  sewing  together  the  raw  surfaces,  a  speedy  cure 
can  be  achieved.  5.  Erosions,  catarrhal,  granular,  and  follicular,  of  the 
cervix,  even  in  nulUparse,  which  are  well  known  to  be  exceedingly  obstinate 
to  the' usual  caustic  and  astringent  treatment.  By  trimming  off  the  eroded 
surface  and  uniting  its  edges  with  sutures,  a  much  more  rapid  and  certain 
cure  can  be  attained  than  by  the  old  methods  (see  Figs.  100,  101,  102,  and 

234  to  240). 

I  consider  the  operation  not  indicated  (not  coujifer -indicated,  merely  not 
called  for)  when  the  lesion  is  shght,  when  there  is  no  erosion  or  but  little 
eversion,  no  hyperplasia  or  other  of  the  symptoms  mentioned  ;  where  ex- 
perience has  shown  palliative  treatment  to  be  sufficient  to  relieve  the  sUght 
discomfort ;  and  where  there  is  absolutely  no  symptom  present  referable 
to  the  tear.  Thus  I  have  repeatedly  declined  to  operate  on  lacerations 
even  of  the  third  degree,  when  there  was  neither  eversion,  erosion,  cervical 
catarrh,  nor  other  symptoms  present.  On  the  other  hand,  I  have  operated 
on  slight  lacerations  when  the  symptoms  seemed  to  warrant  it,  and  have 
never  had  occasion  to  repent  my  action. 

In  considering  the  advisability  of  performing  trachelorrhaphy  in  a 
doubtful  case,  such  as  a  slight  laceration  with  moderate  eversion  and  ero- 
sion, the  gynecologist  should  remember  that  by  a  trifling  operation  he  can 
in  a  couple  of  weeks  permanently  cure  his  patient,  while  the  tedious  and 
uncertain  palliative  treatment  will  probably  occupy  several  months  ;  and  he 
should  place  the  facts  and  the  alternative  squarely  before  the  patient  and 
let  her  decide.  Many  patients  recoil  from  the  mere  word  "  operation,"  and 
would  rather  undergo  any  local  treatment  than  be  "cut."  Such  timid 
people  should  be  spared  that  word,  and  merely  be  told  that  the  "  tear  wdll 
have  to  be  sewed,"  when  their  consent  is  usually  obtained. 

A  rather  remote  indication,  and  one  which  the  physician  should  not 
take  undue  advantage  of,  is  the  moral  effect  which  the  knowledge  of  having 
a  "  torn  womb  "  has  on  a  patient's  mind,  and  her  desire  to  be  restored  to 
as  nearly  perfect  a  condition  as  possible.  Unquestionably,  in  pronounced 
cases,  this  indication  for  trachelorrhaphy  is  perfectly  allowable. 

Operation. 

In  no  operation  in  gynecology  is  it  more  essential  to  be  provided  with 
the  proper  instruments  than  in  that  of  hystero-trachelorrhaphy.  The 
necessity  of  operating  through  a  speculum,  the  usual  tough  character  of 
the  tissue  of  the  cervix,  the  mobility  of  the  uterus,  and  the  confined  and 
limited  field  of  operation,  render  this  otherwise  comparatively  trifling 
operation  one  of  the  more  difficult  procedures  of  operative  gynecology, 
dexterity  in  which  can  only  be  acquired  by  practice.  Hence  it  is  partic- 
ularly important  that  the  part  to  be  operated  on  should  be  freely  ex- 


INDICATIONS    FOR    TEACHELORRHAPHY.  459 

posed,  that  the  scissors  with  which  the  paring  is  done  should  have  the 
proper  curves  and  the  requisite  sharpness  ;  that  the  tenacula  with  which 
the  cervix  is  drawn  down  and  steadied,  should  be  correctly  bent  and 
of  stout,  inflexible  steel,  with  hooks  of  the  right  length  ;  that  the  needles 
should  be  sharp,  of  proper  length,  curve,  and  temper  ;  the  Ki'lk  which 
carries  the  wire  sufficiently  strong  not  to  break  at  the  critical  moment 
when  the  wire  is  being  drawn  through  ;  and  finally,  the  wii'e  of  pure 
silver,  and  the  correct  size,  so  as  not  to  crack  or  twist  off  when  the  edges 
are  approximated.  While  all  these  points  are  of  importance  in  every 
operation,  they  are  of  especial  interest  in  trachelorrhaphy,  where  the  field 
of  operation  lies  in  a  cavity,  and  where  everything  has  to  be  done  through 
the  mediation  of  long-handled  instruments,  every  one  of  which  needs  to 


Fig.  245. — Emmet's  Cervix  Scissors. 


be  picked  up  and  laid  down  again  so  many  times  in  the  regular  course  of 
a  successful  operation,  that  any  interruption  or  accident,  such  as  the  bend- 
ing or  breaking  of  a  needle,  the  tearing  of  the  silk  looj:)  in  a  needle,  or  the 
cracking  of  the  wire  while  being  twisted,  or  even  the  repeated  tearing  out 
of  the  tenaculum  from  the  naturally  brittle  tissue  of  the  torn  surface  while 
paring,  greatly  prolongs  the  operation  and  renders  it  unsatisfactory  to  the 
ojjerator.  It  is  therefore  particularly  advisable,  before  beginning,  to  in- 
spect the  instruments  and  to  note  whether  everything  is  as  it  should  be. 

The  following  instruments  are  necessary  for  trachelorrhaphy  : 

A  broad,  short,  flat,  Sims  operating  speculum. 

A  depressor  with  wooden  handle. 

2  solid  steel  tenacula,  made  for  trachelorrhaphy. 

1  small  hook,  slender  tenaculum. 

2  Emmet's  small  cuiwed  cervix  scissors,  right  and  left. 
1  Emmet's  stout  needle-holdei'. 

1  Munde's  counter-pressure  hook. 

1  Emmet's  twisting  forceps. 

1  Sims'  shield. 

1  stout  wire  scissors. 

6  Schnetter's  cervix  needles,  long  and  medium. 

6  Sims'  or  Hanks'  cervix  needles,  long  and  medium. 

Braided  silk,  medium  size. 

Pure  silver  wire.  No.  27,  several  coils,  and  one  coil  No.  33  (fine,  for 
superficial  sutures). 

6  metal  sponge-holders.  Fine  grained,  cheap  sponges,  to  be  cut  into 
suitable  pieces. 

1  Simpson's  sound. 


460  GYNECOLOGICAL    OPERATIONS. 

If  no  broad  operating  speculum  is  at  Land,  the  ordinary  Sims  -will  do 
very  well,  and  I  laave  frequently  operated  through  my  flange  speculum. 
If  the  vagina  is  very  capacious,  with  flabby  walls,  the  flat  speculum  is  de- 
cidedly preferable.  The  solid  steel  tenacula  have  handles  with  wooden 
coating,  and  are  highly  tempered,  so  as  not  to  bend  when  the  cervix  is 
steadied  by  them  during  the  passage  of  the  needles  ;  the  ordinary  tenacula 
are  liable  to  bend  so  much  as  to  be  useless.  The  small-hooked  tenaculum 
is  intended  to  hook  up  the  flap  to  be  removed  ;  a  long-hooked  tenaculum 
would  enter  so  deeply  as  to  be  in  the  way  of  the  blade  of  the  scissors. 

The  slender  sharply  curved  cervix  scissors  are  liable  after  several  oper- 
ations to  become  loose  in  the  joint  and  to  feather  while  cutting  ;  it  is  well, 
therefore,  to  inspect  them  when  preparing  for  an  operation,  and  to  have 
the  screw  tightened  if  it  is  found  loose. 

The  counter-pressure  hook  is  used  to  steady  the  posterior  lip  of  the 
cerv'ix  while  the  needle  is  being  forced  through,  its  point  passing  between 
the  two  prongs  of  the  hook. 

The  T^-ire  scissors  are  merely  long-handled,  stout  scissors  which  cut 
well  down  to  the  point. 


Fig.  24G. — Munde's  Counter-pressure  Hook  for  Trachelorrhaphy. 

Schnetter's  needles  were  not  originally  intended  for  trachelorrhaphy, 
but  I  chanced  to  see  them,  and  found  them  so  useful  that  I  now  employ 
them  almost  exclusively.  There  are  three  sizes,  one  and  one-half  inch,  one 
inch,  and  three-quarters  of  an  inch  ;  the  latter  are  too  short  for  this  oj)era- 
tion.  The  peculiarity  of  this  needle  is  that  it  pierces  the  tough  tissue  of 
the  cervix  more  easily  than  any  other  needle,  except  a  spear  or  lance-point, 
which  makes  a  larger  hole,  and  is  liable  to  cause  more  oozing.  Schnetter's 
needle  has  an  anterior  and  posterior  cutting  edge,  and  is  convex  on  either 
side.  The  majority  of  operators,  I  beheve,  still  use  the  old  Sims-Emmet 
cei-vix  needle,  as  I  did  until  a  year  ago.  It  is  a  stout  round  needle,  of  two 
lengths,  with  shght  curve,  and  whittled-off  point  on  the  concave  surface. 
It  is  well  to  have  both  kinds,  and  to  be  plentifully  supplied,  as  one  may 
break  or  bend  several  needles  at  any  operation. 

Of  course,  other  needles  will  answer  for  this  operation,  if  they  are  only 
stout  and  have  a  cutting  point,  but  the  two  kinds  mentioned  are,  so  far  as 
I  know,  the  best.  Recently  Dr.  H.  T.  Hanks,  of  New  York,  has  intro- 
duced a  very  good  needle,  which  is  round  with  a  posterior  cutting  surface 
at  the  point.  A  round  needle  with  a  simple  point,  like  a  darning-needle, 
is  the  very  worst  possible  one  to  thrust  through  a  dense  cervix  ;  and  a 
flat,  sharp,  surgical  needle  is  almost  certain  to  break  or  bend. 

At  least  three  needles  should  be  threaded  for  a  ceiwix  operation,  two 
long  and  one  short ;  but  I  usually  have  six  or  more  ready,  to  avoid'  pos- 
sible delay  in  case  of  accident.  How  to  thi'ead  them  has  akeady  been  de- 
scribed in  the  introductory  section. 


INDICATIONS    FOR    TRACHELORRHAPHY.  461 

Assistmits. — Four  assistants  are  needed,  two  of  whom — the  one  in 
charge  of  the  ether,  and  the  one  to  hand  the  instruments,  thread  needles, 
etc. — must  be  physicians  ;  of  the  other  two,  one  can  be,  and  usually  is,  a 
nurse,  who  holds  the  speculum,  and  the  other  also  a  nurse,  or  some  person 
who  does  not  faint  at  the  sight  of  blood,  to  wash  and  hand  the  sponges  on 
their  holders.  Of  these  assistants,  the  etherizer  must  necessarily  be  a 
thoroughly  reliable  man  ;  the  others  can  be  beginners,  although  a  trained 
nurse  and  an  assistant  thoroughly  conversant  with  the  instruments  used 
in  this  operation  are  (as  in  every  operation  where  assistants  are  required) 
sources  of  great  comfort  to  the  operator.  I  should  always  advise  the  oper- 
ator to  be  provided  with  good  assistance,  and  plenty  of  it ;  it  is  in  the  in- 
terest of  the  patient  not  to  have  delays  and  accidents  through  insufficient 
or  incompetent  assistance.  Li  addition  to  the  four  named,  it  is  always 
well  to  have  some  woman  at  hand  to  bring  fresh  water,  empty  the  soiled 
water,  hold  the  basin  if  the  patient  vomits,  etc. 

Preparation  of  the  Patient. — The  general  preparatory  measures,  such  as 
tonics,  regulation  of  functions  of  skin,  kidneys,  bowels,  etc.,  have  akeady 
been  referred  to  in  the  General  Chapter. 

The  local  pi*eparatory  treatment  immediately  preceding  the  operation 
consists  in  securing  a  thorough  evacuation  of  the  bowels  by  a  laxative  on 
the  day  before  the  operation  (generally  taken  on  the  evening  of  the  last 
but  one  before),  followed  by  one  or  more  enemata  on  the  morning  of  the 
operation,  in  order  to  clear  out  the  rectum  and  prevent  the  unpleasant  oc- 
currence of  the  oozing  or  squirting  of  fluid  feces  from  the  anus  dvu'ing 
the  frequent  retching  and  vomiting  while  under  ether,  an  accident  veiy 
liable  to  happen  if  the  laxative  was  not  given  until  the  night  before  and 
had  not  finished  acting  when  the  operation  was  begun.  Further,  im- 
mediately before  the  anesthetic  is  administered,  a  copious  vaginal  douche 
of  hot  (110°  F.,  or  more)  carbolized  (two  per  cent.)  water  should  be  given, 
to  contract  the  utero-vaginal  capillaries  ;  if  preferred,  this  douche  may  be 
given  when  the  patient  is  anesthetized  and  on  the  table,  which  is  perhaps 
the  better  plan.  The  opzing  during  the  operation  is  greatly  diminished 
by  this  practice.  An  astringent  should  not  be  added  to  the  injection, 
however,  as  it  would  contract  the  vagina  too  much. 

The  manner  of  giving  the  anesthetic  differs  in  no  way  from  that  for 
other  operations,  and  has  already  been  described  in  the  Introductory  Chap- 
ter. In  one  respect,  however,  trachelorrhaphy  differs  from  all  longer  op- 
erations on  the  female  genitals  or  elsewhere,  in  that  it  is  possible,  even  in 
our  day  of  invariable  anesthetic  operations,  to  perform  it  without  an  anes- 
thetic and  without  the  patient  experiencing  very  sevei-e  pain.  The  cervix 
is  not,  as  a  rule,  a  very  sensitive  organ,  and  the  pain  inflicted  dvu'ing  tra- 
chelorrhaphy is  chiefly  that  produced  by  the  dragging  and  jiu-ring  of  the 
uterus  during  the  forcing  through  of  the  needles  ;  the  paring  is  seldom 
complained  of.  I  have  thus  performed  the  operation  some  eight  or  ten  times 
without  an  anesthetic,  usually  because  it  promised  to  be  a  rapid  and  easy 
case  and  the  patient  preferred  a  small  amount  of  pain  to  the  discomfort  of 
the  anesthesia  and  the  nausea  following  it,  and  once  because  a  mitral  ste- 


462  GYNECOLOGICAL    OPEEATIONS. 

nosis  prohibited  the  administration  of  an  anesthetic.  But  I  have  decided 
that,  with  this  one  exception  of  organic  cardiac  or  pulmonary  disease,  or 
of  an  unusually  irritable  stomach,  I  shall  not  again  omit  the  anesthetic, 
because  the  nervous  shock  of  being  conscious  of  every  step  of  the  opera- 
tion and  the  cramped  position  on  the  table  for  half  an  hour  or  longer, 
seem  to  leave  an  effect  on  the  patient  scarcely  less  unpleasant  than  the 
temporary  consequences  of  the  anesthetic.  Besides,  the  expressions  of 
pain  which  more  or  less  involuntarily  escape  even  the  most  courageous 
woman,  at  times,  during  trachelorrhaphy  are  liable  to  induce  the  operator 
to  hasten  the  operation  and  thus  do  his  work  less  thoroughly  than  if  he 
were  entirely  untrammelled  as  to  time  and  the  patient's  sensations. 

In  cases  where  an  anesthetic  is  inadmissible,  the  patient's  sensibility 
may  be  blunted  by  giving  her  a  drachm  of  one  of  the  bromides  in  divided 
doses  some  hours  before  the  operation,  or  a  morphine  suppository  and  a 
couple  of  ounces  of  whiskey  half  an  hour  before,  or  all  of  these  together, 
if  she  is  exceptionally  nervous. 

Details  of  Operation. — The  operating  table  is  placed  in  front  of  a  win- 
dow so  as  to  have  the  light  fall  on  its  lower  end  over  the  right  shoulder  of 
the  operator,  who  sits  slightly  to  the  left  of  the  centi'e  of  the  lower  end  of 
the  table.  The  instruments  are  spread  on  a  smaller  table,  covered  with  a 
clean  white  cloth,  to  the  right  of  the  operator,  or  they  may  be  bathed  in  a 
weak  disinfectant  fluid  contained  in  flat  pans  ;  but,  if  they  have  been  prop- 
erly cleansed  and  disinfected  immediately  before  the  operation,  this  usu- 
ally suffices  ;  the  basin  with  ice-water,  containing  the  sponges  attached  to 
the  holders,  stands  on  a  table  or  chair  to  the  right  of  the  first  assistant,  who 
takes  the  cleaned  and  dry  squeezed  sponges  from  the  nurse  and  does  the 
sponging  as  occasion  requires,  and  hands  the  soiled  sponges  back  to  the 
nurse.  A  bucket  for  slops  stands  by  the  nurse.  The  sj)eculum  and  de- 
pressor are  in  a  basin  of  warm  water  on  a  chair  immediately  to  the  right 
of  the  operator,  who  dips  the  instruments  in  it  at  will  during  the  operation 
as  they  become  clogged  or  clotted  with  blood. 

The  patient  is  placed  on  the  table  in  Sims'  position  (the  anesthetic 
having  usually  been  given  in  her  bed  or  in  an  adjoining  room  while  the 
instruments  are  being  prepared),  the  operator  introduces  the  operating 
speculum,  exposes  the  cervix  and  cleanses  it  carefully  of  mucus  with  a 
sponge  on  its  holder,  and  then  grasps  the  cervix  firmly  with  the  stout, 
right-angle  hook  tenaculum  at  the  spot  where  he  intends  to  make  the  first 
incision,  seizes  the  scissors  curved  to  the  left,  and  begins  with  a  quick  clip. 
If  the  laceration  is  a  bilateral  one,  whether  of  equal  depth  or  not,  or  if  it 
be  on  the  left  side  only,  the  incision  begins  at  a,  the  flap  held  by  the  tenacu- 
lum on  the  anterior  lip  is  rapidly  trimmed  off  down  to  e,  and  then,  care 
being  taken  to  excise  all  the  cicatricial  tissue  down  to  the  very  bottom  of 
the  angle  ate,  is  carried  on  the  posterior  Hp  to  a  corresponding  point 
b  with  the  point  of  commencement  a,  on  the  anterior  lip.  To  make  sure 
that  the  flap  on  the  posterior  lip  is  not  larger  than  the  anterior,  it  is  well 
to  mark  its  limit  at  b,  with  the  other  scissors  (right  curve),  before  cutting 
out  with  the  first  pair.     If  this  flap  fi-om  a  to  e  to  6,  can  be  removed  in 


INDICATIONS    FOE    TRACHELORRHAPHY. 


463 


Fig.  247.— Surfaces  Denuded  in  Bilateral  Trache- 
lorrhaphy. Undenuded  strip  for  cervical  canal  in 
centre  (P.  F.  M.). 


one  piece,  time  will  be  saved.  If  the  right-angle  tenaculum  tears  out,  the 
small-hooked  slender  tenaculum  may  be  substituted,  and  with  it  the  angle 
e  well  lifted  up  to  make  sure  of  its  being  thoroughly  cut  out.  The  tearing 
out  of  the  tenacula  is  a  source  of  great  annoyance  in  this  operation,  and  if 
the  tissues  are  grasped  too  deeply,  the  scissors  will  cut  on  the  tenaculum. 
Merely  the  mucous  membrane  or  cicatricial  tissue  is  trimmed  off ;  the  mus- 
cular tissue  need  not  be  removed  unless  it  is  hyperplastic  and  the  lips  re- 
sist coaptation.  It  will  be  noticed  by  looking  at  the  diagram  that  the  in- 
ternal border  of  the  pared  surface 
is  so  placed  as  to  be  on  a  line  with 
the  edge  of  the  prospective  cervi- 
cal canal  and  external  os,  which 
should  be  about  one-fourth  of  an 
inch  in  diameter.  The  same  rela- 
tion is  to  be  observed  on  the  other 
side  of  the  cervix,  if  the  rent  is 
bilateral.  After  the  flap  has  been 
removed,  and  the  borders  of  the 
wound  have  been  trimmed  smooth- 
ly, they  should  be  brought  togeth- 
er with  tenacula  to  see  whether  they  fit  and  are  Ukely  to  make  a  clean  cica- 
trix. The  operator  now  proceeds  to  denude  the  other,  or  right  side  of  the 
rent,  beginning  at  c  and  trimming  off  a  flajD  (c  e  d)  corresponding  to  the 
left  side  in  the  same  manner.  If  the  rent  on  one  side  should  be  smaller 
than  on  the  other,  of  course  the  denuded  surface  will  also  be  smaller.  If 
necessary,  the  denudation  may  extend  slightly  on  the  vaginal  mucous  mem- 
brane proper,  but  care  should  be  taken  not  to  go  too  far,  as  then  a  larger 
number  of  sutures  are  required,  and  puckering  is  likely  to  take  place. 

While  it  is  important  to  excise  all  the  cicatricial  tissue  in  the  angles  of 
the  rent,  it  is  well  to  remember  that  too  deep  or  extensive  an  incision 
brings  the  risk  of  cutting  the  circular  artery  or  one  of  its  branches.  Should 
this  occur,  or  if  the  parenchymatous  oozing  is  at  all  profuse,  it  can  gener- 
ally be  arrested  without  difficulty  by  passing  a  deep  Avire  suture  thi-ough 
the  vaginal  roof  at  the  very  bottom  of  the  angle  and  twisting  it  at  once. 

The  cervical  tourniquet  recommended  by  Emmet  has  never  been  re- 
quired in  m}'  practice,  nor  have  I  ever  seen  him  use  it.  In  marking  out 
the  limits  of  the  external  os,  care  should  be  taken  to  leave  that  orifice 
somewhat  larger  than  the  canal  above,  so  as  to  make  the  cervical  canal 
slightly  funnel-shaped.  The  contraction  naturally  occurring  at  the  exter- 
nal OS  during  cicatrization  renders  this  precaution  necessary  to  avoid  hav- 
ing subsequently  a  too  narrow  orifice.  I  shall  mention  further  on  how 
this  contraction  may  be  prevented.  The  utmost  care  should  be  observed 
to  cut  out  ail  retention-cysts  ("ovula  Nabothi")  which  are  situated  in  the 
line  of  denudation ;  merely  opening  them  is  not  sufiicient,  as  they  will  fill 
again,  and  either  interfere  with  primary  union  or  later  cause  nodular  ir- 
regularities on  the  cervix.  Each  follicle  should  be  lifted  with  a  tenaculum 
and  cut  out  with  scissors.     The  raw  surfaces  and  their  edges  having  been 


464 


GYNECOLOGICAL    OPERATIONS. 


trimmed  smooth,  and  on  coaptation  with  tenacula  appearing  symmetrical, 
the  sutures  are  introduced,  the  first  being  passed  through  the  vaginal 
mucous  membrane  and  cervical  tissue  at  the  angle  of  the  upper  or  right 
tear,  if  there  is  much  oozing,  in  order  to  stop  the  blood  fi'om  flowing  over 
the  field  of  operation  below.  This  first  suture  is  introduced  thi'ough  the 
anterior  lip,  at  a  right  angle  to  the  cervical  canal,  and  then  passed  through 
the  postei'ior  lij)  fi'om  within  outward  in  the  same  manner,  entering  and 
escaping  about  one-quarter  inch  from  the  edge  of  the  wound.  It  is  weU 
to  hook  and  fasten  the  wire  in  the  silk  loop  before  beginning  the  suture, 
as  by  a  rapid  jerk  in  pulling  out  the  needle  the  short  silk  loop  might  also 
be  pulled  entirely  through  and  out,  Counter-pressui-e  is  made  by  a  solid 
tenaculum  on  either  lip,  or  by  the  counter- j)ressure  hook  on  the  posterior 
lip,  if  the  tenaculum  tears  out  and  produces  much  gashing.  The  object 
of  passing  this  and  all  the  subsequent  sutures  (except  the  innermost  one 


Fig.  248.— Introduction  of  Snlurea  in  Trachelorrhaphy  (P.  F.  M.). 

on  each  side)  at  a  right  angle  to  the  cei-vical  canal,  bringing  each  out  in 
the  undenuded  tissue  of  the  canal  on  the  anterior  lip  and  reinserting  it  in 
the  same  manner  in  the  posterior  lip,  is  to  secure  perfect  adaptation  of  the 
flaps  and  prevent  imperfect  union  in  the  canal. 

The  first  suture  having  been  passed,  the  ends  of  wire  are  twisted 
loosely  and  handed  to  the  nurse,  who  holds  the  speculum,  to  guard  with  her 
left  hand,  if  it  be  the  upper  angle  which  is  first  sewed,  or  they  are  turned 
down  under  the  angle  of  the  speculum  and  kept  there  if  the  left  tear  is 
the  one  being  sutured.  The  next  sutures  are  introduced  in  the  same 
manner  until  the  last  one  is  reached,  which  is  passed  straight  across  close 
to  the  edge  of  the  proposed  external  os.  This  is  done  in  order  to  make 
the  hps  of  the  os  come  smoothly  together  without  evertino-  when  the  sut- 
ures are  twisted. 

Four  deep  sutures  on  either  side  will  usually  suffice,  althouc^h  occa- 
sionaUy,  m  deep  unilateral  tears,  five  or  six  are  requii'ed,  and  once,  in  a 


INDICATIO]S"S    FOE    TKACHELOERIIAPHY. 


465 


large  irregular  tear  of  a  prolapsed  uterus,  I  used  ten  sutures  on  one  side. 
One  or  more  superficial  sutures  may  be  required  if  there  is  any  gaping  or 
puckering  after  the  sutures  are  twisted. 

It  is  important,  of  course,  to  see  that  the  points  of  entrance  and  of 
exit  on  either  lip  correspond  as  nearly  as  possible  in  location,  and  that 
sutures  do  not  cross  each  other  in  the  tissue,  which 
would  produce  strangulation  of  that  part  and  conse- 
quent sloughing.  To  be  sure  that  the  sutures  an- 
swer the  j)urpose  of  neatly  coaptating  the  lips,  it  is 
well  to  draw  the  lips  together  for  a  moment  imme- 
diately after  each  suture  is  passed  by  crossing  the 
ends  of  the  wire. 

The  sutures  having  all  been  introduced  on  both 
sides,  they  are  twisted  (as  described  in  the  Intro- 
ductory Section),  care  being  taken  to  coaptate  the 
lips  of  the  wound  with  tenacula  as  nearly  as  possible. 
As  each  suture,  beginning  with  the  one  nearest  the 
angle,  is  twisted  down  to  the  surface,  it  is  bent  short 
over  a  tenaculum  and  laid  flat  against  the  anterior 
lip  of  the  cervix,  and  there  cut  off  by  a  quick  clip  of  the  wire-scissors,  not 
more  than  one-quarter  inch  from  the  junction,  so  as  not  to  leave  the  end 
projecting.  This  is  a  point  of  considerable  importance.  Usually  I  turn  the 
sutures  down  in  front,  as  they  are  more  easy  to  find  there  when  the  time 
comes  to  remove  them.  But  at  times  I  have  laid  them  down  alternately  in 
front  and  behind,  so  as  to  act  as  splints  to  the  lips.     But  I  do  not  think 


Fig.  240.— Sutures  T\Wst- 
cd  and  Turned  Down  in 
Bilateral  Trachelorrhaphy 
(P.  F.  M.). 


Fig.  250.— Section  View  of  Introduc- 
tion of  Sutures  in  Trachelorrhaphy  (P. 
F.  M.). 


Pig.  251.— Section  of  Sutures  Twisted 
in  Trachelorrhaphy  (P.  F.  M.). 


this  plan  much  of  an  improvement.  If  there  is  any  gaping  or  puckering 
along  the  line  of  union,  it  can  now  be  remedied  by  as  many  superficial, 
Ko.  33  wire,  sutures  as  necessary.  The  sutures  should  always  be  counted 
and  their  number  noted  down  by  the  operator,  assistant,  or  nurse,  so  that 
30 


466  GYNECOLOGICAL    OPERATIONS. 

none  wliicli  may  have  buried  themselves  in  the  tissues  will  be  forgotten 
when  they  are  removed  a  week  or  more  later. 

Particular  attention  should  be  paid  not  to  twist  the  sutures  too  tight ; 
the  hne  of  union  should  be  as  smooth  and  free  from  puckering  between 
the  stitches  as  possible.  And  if  any  spot,  usually  the  lips  of  the  prospec- 
tive external  os,  appear  blanched,  one  or  both  of  the  nearest  sutures  had 
better  be  loosened  a  httle  by  passing  two  tenacula  under  the  stitch  and 
separating  them,  or  else  sloughing  of  this  part  is  very  liable  to  occur. 

All  the  sutures  having  been  twisted  and  cut  short,  the  sound  is  passed 
through  the  newly  made  external  os  to  the  fundus,  to  make  sure  that  the 
canal  is  thoroughly  pervious,  the  blood  is  sponged  or  washed  away,  and  the 
speculum  is  removed.     The  operation  is  finished. 

If  an  easy  case,  or  if  unilateral,  it  may  have  occupied  but  twenty  or 
thu-ty  minutes;  if  very  extensive,  or,  if  mishaps  have  occurred,  in  the 
shape  of  hemorrhage,  breaking  of  needles  or  wire,  etc.,  it  may  have  lasted 
longer  than  thirty,  and  even  forty-five  minutes.  The  more  dexterous  the 
operator,  the  more  rapid,  as  a  rule,  the  operation.  But  it  is  essentially 
true  of  this  particular  operation,  that  the  more  hurry  the  less  advance,  and 
that,  to  be  well  done,  it  must  not  be  hurried. 

The  patient  is  now  I'emoved  to  her  bed,  and,  when  conscious,  is  given  a 
hot  vaginal  douche  of  a  one  to  two  thousand  corrosive  sublimate  or  two  per 
cent,  carbolic  acid  solution,  with  or  without  alum,  as  the  preference  of  the 
operator  may  decide.  This  is  done  j)artly  as  an  antiseptic  and  partly  as  a 
styptic  against  possible  parenchymatous  oozing. 

Possible  Modifications  in  the  Operative  Details. — Following  the  lead  of 
Emmet,  I  greatly  prefer  the  scissors  for  this  operation  ;  but  in  former 
years  I  have  repeatedly  performed  it  with  the  knife,  using  slender  blades 
attached  at  right  angles  to  a  long  handle,  which  I  broiight  with  me  from 
Heidelberg,  where  Simon  had  introduced  them  for  vesico- vaginal  fistula 
operations.  They  were  quite  useful  in  picking  out  the  "cicatricial  plug." 
But  when  the  fine  curved  scissors  now  in  use  were  made  I  no  longer  had 
any  difficulty  in  thoroughly  cutting  out  the  angles,  and  since  tlien  have 
not  used  the  knife. 

Special  instruments  have  been  contrived  by  Skene  and  others  to  punch 
out  the  "  cicatricial  plug,"  but  I  do  not  think  they  are  generally  employed. 

If  the  cervical  tissue  is  very  friable,  and  the  tenaculum  is  constantly 
tearing  out,  a  very  good  way  of  securing  a  firm  hold  and  guiding  the  part 
during  the  operation  is  to  pass  a  silver  suture  through  both  lips,  close  to 
the  prospective  external  os,  and  twist  the  ends  lightly  ;  the  cervix  can  then 
be  drawn  down  and  from  side  to  side  by  this  suture,  as  the  operator  may 
desire.  Or  it  may  be  passed  only  through  the  anterior  lip,  if  it  appears 
that  the  lips  are  too  much  approximated  for  careful  paring  or  suturing 
when  the  wire  goes  through  both.  This  suture,  if  properly  placed,  may 
then  be  left  and  utilized  when  the  wound  is  to  be  closed. 

If  at  any  time  during  the  operation  the  oozing  becomes  too  profuse  or 
annoying,  the  upper  suture  next  to  the  angle,  or  all  the  sutures  on  one 
side  may  be  inserted  and  twisted  at  once  before  paring  or  suturing  the 


INDICATIONS    FOR   TRACHELORRHAPHY. 


467 


Fig.  252.— Line  of  Denudation  in  Bifid  Poste- 
rior Fissure.  The  dots  show  flaps  to  be  excised 
(P.  P.  M.). 


other  side.     This  usually  arrests  profuse  oozing  at  once,  or  they  may  be 
twisted  loosely,  and  undone  later  on  to  be  twisted  permanently. 

I  have  never  known  an  alarming  hemorrhage,  or  one  that  was  not  im- 
mediately arrested  by  twisting  one  or  all  of  the  sutures,  occur  in  this 
operation.  Should  there  be  any  doubt  as  to  whether  the  deepest  ujoper- 
most  suture  has  effectually  compressed  the  spurting  artery  in  the  angle, 
another  still  deeper  suture  can  be  passed 
through  the  vaginal  vault,  above  the 
first,  and  twisted  in  the  usual  manner. 

Anterior  and  posterior  lacerations 
are  operated  on  after  the  same  principle. 
There  is  less  danger  of  hemorrhage,  but 
care  must  be  taken  in  the  anterior  va- 
riety not  to  pass  the  first  suture  too  far 
out  for  fear  of  by  an  unlucky  chance  in- 
cluding one  or  the  other  ureter  near  its 
termination  in  the  base  of  the  bladder.  Irregular  lacerations,  like  bifid  or 
stellate,  are  best  treated  by  excising  redundant  tissue  and  flaps,  and  mak- 
ing either  a  unilateral  or  bilateral,  or  an  anterior  or  posterior  fissure  out  of 
them.  To  endeavor  to  pare  and  sew  together  the  lips  of  the  various  fis- 
sures separately  would  surely  result  in  failure  as  to  union,  or  in  a  cicatri- 
cially  contracted,  misshaped  ceiwix. 

It  is,  of  course,  important  to  always  place  the  external  os  at  the  very 
apex  of  the  cone  represented  by  the  newly  formed  cervix  ;  a  lateral  os 
would  probably  be  a  cause  of  sterility.     In  certain  cases  of  cervical  hyj)er- 

plasia  it  is  necessary  to  cut  away  so 
]t>  much  tissue  from  one  or  both  lij^s  to 

enable  smooth  coaptation,  that  the 
cervical  canal  and  external  os  have 
to  be  encroached  upon.  When  this 
is  necessary,  or  when  by  cai-elessness 
or  accident  the  external  os  has  been 
left  too  small,  a  glass  stem,  such  as 
is  used  in  flexions,  may  be  inserted 
when  the  sutures  have  all  been 
twisted,  and  left  i)i  situ  (if  well 
borne)  until  the  sutures  are  re- 
moved. If  then  thought  advisable, 
it  may  again  be  introduced  and  re- 
tained so  long  as  the  patient  is  in 
bed.  It  does  not  seem  to  interfere 
with  union,  and  certainly  secures  a 
patulous  cenical  canal. 
When  the  lips  of  the  cervix  have  become  so  hyperplastic  and  dense  as 
to  prevent  their  approximation  by  tenacula,  it  is  necessary  to  excise  more 
tissue  than  is  usually  done.  Instead,  therefore,  of  merely  paring  off  the 
cicatricial  or  mucous  tissue  from  either  lip,  a  distinct  wedge  of  uterine 


XX 


Fig.  233. — Wedge-shaped  Excision  in  Hj'perplasia 
of  Lacerated  Cervix,  Showing  Outline  of  Incisiona 
(P.  P.  M.). 


468 


GYNECOLOGICAL    OPERATIONS 


substance  should  be  excised  as  shown  in  Fig.  253.  One  blade  of  the  stout 
perineum  scissors  (see  Fig.  261)  is  passed  into  the  cervical  canal  and  a 
cut  is  made  through  the  anterior  lip  to  a  ;  this  incision  is  then  carried  to 
b,  in  the  upper,  or  right  angle  of  the  rent.  A  similar  incision  is  then  made 
in  the  posterior  lip  to  a',  and  the  wedge  finally  excised  by  a  cut  o'  to  b. 
The  same  procedure  is  repeated  in  the  lower,  or  left  angle,  of  the  rent. 
The  cervix  then  presents  the  appearance  shown  in  Fig.  254,  a  thick,  tri- 
angular wedge  having  been  excised  from  each  lateral  angle  of  the  tear. 

The  sutures  are  introduced  in  the 
usual  way.  A  branch  of  the  cir- 
cular artery  is  very  liable  to  be 
cut  in  this  operation,  but  the 
deep  vaginal  suture  will  at  once 
aiTest  hemoiThage. 

Some  operators  habitually  use 
silk  sutures  only,  and  Dr.  Skene, 
of  Brooklyn,  reports  excellent 
success  with  this  material.  I 
doubt  not  that  it  is  quite  as  good 
as  wire,  but  having  once  become 
used  to  and  being  satisfied  with 
the  latter,  I  have  had  no  desire 
to  change.     Besides,  it  must  at 

Fig.  2o4. — Appearance  of  Eaw  Surfaces  and  Introdnc-  i        t/v 

tion  of  Sntiires  in  Wedge  shaped  Excision  of  Lacerated  timeS  be  drmcult  to  knot  the  Silk 
Cervix  (P.  i'.  M. ).  ■,  •    ^  ■       ,-, 

high  up  m  the  vagina. 

In  Gei-many,  the  dorsal  position  is  generally  used  for  trachelon-haphy, 
the  cei-vix  being  exposed  through  Simon's  or  Fritsch's  specula.  We  here 
are  too  well  satisfied  with  the  Sims  to  care  to  change. 

Precautions  during  the  Ojyei^ation. — While  a  moderate  amount  of  traction 
on  the  cervix  is  necessaiy,  unavoidable,  and  justifiable,  care  should  be  taken 
not  to  use  too  forcible  or  too  rapid  traction,  especially  if  there  be  the  least 
suspicion  of  adhesions.  One  cervix  may  be  drawn  to  the  vulva  with  the 
gi-eatest  ease  and  Avithout  the  slightest  danger  of  inflammatory  reaction, 
while  another,  apparently  equally  mobile,  scarcely  descends  half  an  inch 
without  force.  The  more  children  a  woman  has  had,  ceteris  paribus,  the 
more  movable  is  her  uterus. 

Further,  in  cutting  out  the  angle,  remember  not  to  cut  too  deeply  or 
too  far  into  the  vaginal  tissue  ;  and,  above  all,  leave  the  external  os  suffi- 
ciently large,  so  that  no  subsequent  contraction  can  possibly  produce  sterility. 

After-treatment.— This  is  exceedingly  simple.  For  the  first  few  days 
the  diet  is  fluid,  until  the  bowels  are  moved,  which  is  done  by  a  mild  laxa- 
tive, with  or  without  enema,  on  the  third  day  ;  after  that,  ordinary  food 
may  be  permitted,  the  bowels  being  moved  eveiy  day.  One  tepid,  carbo- 
lized  vaginal  douche  per  day  is  given,  if  there  is  no,  or  but  shght,  oozmg. 
If  there  is  bloody  discharge  of  any  amount  dming  the  first  few  day.s,  as 
may  well  be  the  case  if  the  patient  retched  much  after  being  put  to  bed, 
cue  or  two  teaspoonfuls  of  powdered  alum  should  be  added  to  the  pint  of 


IXDICATIOlSrS    FOR    TRACHELORRHAPHY.  469 

hot  water  ;  and  if  there  is  considerable  discharge  two  douches  per  day  are 
given. 

As  a  rule,  in  cases  which  are  doing  well,  where  the  sutures  are  not  cut- 
ting too  deeply  and  no  sloughing  is  taking  place,  there  is  very  little  or  no 
discharge  of  any  kind,  either  bloody,  serous,  or  mucous,  and  some  oper- 
ators dispense  entirely  with  vaginal  douches. 

The  patient  remains  in  bed  in  a  recumbent  or  shghtly  reclining  posi- 
tion, but  on  no  account  must  she  sit  or  get  up.  If  she  can,  she  must  uri- 
nate in  the  bed-pan,  and  her  bowels  must  move  into  the  same  recej)tacle. 
A  catheter  is  seldom  needed  ;  indeed,  rather  than  employ  it  unnecessarily', 
I  let  the  patient  try  to  urinate  in  the  knee-elbow  iDOsition,  befoi'e  hanng 
the  urine  drawn.  In  this  position  there  is  absolutely  no  downward  press- 
ure on  the  vaginal  vault. 

Usually  patients  suffer  no  pain  after  trachelorrhaphy,  with  the  exception 
of  slight  soreness  in  each  groin  and  some  sacralgia.  The  former  is  due  to 
the  traction  on  the  uterus,  the  latter  to  the  cramped  position  during  the 
operation.  The  majority  of  jiatients  complain  of  the  irksome  confinement 
in  bed,  and  ask  when  they  may  rise  ;  and  such  I  generally  allow  to  read, 
do  light  needlework,  and  see  a  few  visitors. 

Removal  of  Sutures. — Not  sooner  than  the  eighth,  and  usually  not  later 
than  the  tenth,  day  the  sutures  are  removed.  The  bowels  having  been 
moved  the  day  before,  are  left  quiescent  for  forty-eight  hours.  The  vagina 
is  cleansed  by  a  douche,  and  the  patient  placed  in  Sims'  position,  and  the 
speculum  introduced.  It  is  exceeding!}'  important  to  get  a  good  view  of 
the  cervix  for  this  maneuvre,  as  a  sunken  or  imperfectly  visible  suture 
may  detain  one  for  half-an-houi*  or  longei',  and  ill-directed  traction  may 
burst  ojDen  the  freshly  united  wound. 

Having  carefully  cleansed  the  cervix  with  a  sponge,  a  tenaculum  is 
hooked  into  the  posterior  surface  of  the  cervix,  and  the  latter  is  drawn 
gently  dowTi  and  toward  the  anterior  vaginal  wall,  so  as  to  bring  the  black- 
ened sutures  well  into  view.  Beginning  with  the  upper  side  (as  I  usually 
prefer  to  do,  because  it  is  the  most  difiicult),  the  twisted  part  of  the  farthest 
suture  is  caught  in  a  long-catch  dressing-forceps,  and  gently  lifted  from 
its  bed  of  indentation  and  drawn  upon,  until  the  glistening  Avhite  of  its 
point  of  junction  at  the  base  of  the  twist  is  seen,  when  it  is  clipped  witli 
the  wire-scissors,  and  drawn  out  over  the  hue  of  union,  so  as  not  to  separate 
the  lips.  This  maneuvre  is  repeated  until  every  suture  is  removed.  Oc- 
casionally the  tenaculum  is  found  useful  to  seek  and  pick  up  the  hidden 
twist  of  a  suture,  for  the  forceps  to  catch  it.  The  utmost  caution  must 
be  observed  not  to  cut  off  the  suture  at  the  point  where  the  twist  begins, 
as  it  is  almost  impossible  to  find  the  suture  later.  I  have  several  times 
done  this  when  the  suture  was  deeply  buried  ;  or  I  have,  for  the  same 
reason,  overlooked  a  suture,  and  have  found  it  accidentally,  or  have  been 
informed  by  the  husband  of  its  presence,  and  have  removed  it  long  after- 
ward. 

When  all  the  sutures  have  been  removed,  it  is  best  not  to  be  inquisi- 
tive, but  to  wait  a  few  days  longer  before  ascertaining  with  absolute  cer- 


470  GYNECOLOGICAL    OPERATIONS. 

tainty  Tvlietlier  the  result  is  a  i^erfect  one  or  not.  My  experience  has  been 
that  if  the  cervix  looks  smooth  and  has  its  normal  pale  rose-color,  if  the 
sutm-es  lie  flat  as  they  were  originally  placed,  if  the  tissue  between  the 
sutures  is  not  puffy  and  inflamed-looking,  and  if  there  has  been  no  ap- 
preciable discharge,  particularly  no  offensive  secretion  after  the  first  three 
days,  that  union  is  perfect. 

I  usually  place  a  couple  of  flat  tampons  soaked  in  an  alum  or  tannin 
and  glycerine  solution  against  the  cei-vix,  and  have  the  patient  returned  to 
her  bed,  where  she  stays  for  three  or  four  days  longer  until  union  has  be- 
come more  fii'm  and  the  sutui'e  canals  have  closed.  After  the  tampons  are 
removed,  the  usual  douche  is  given  every  day.  On  the  eleventh  to  four- 
teenth day  the  patient  is  allowed  to  sit  up  ;  about  the  thirteenth  or  six- 
teenth day  she  may  walk  about,  and  gradually  go  down  stairs  ;  and  about 
the  twenty-first  day,  or  a  httle  later,  she  is  dii-ected  to  call  at  the  office  for 
a  final  examination. 

If  she  was  wearing  a  pessaiy,  she  may  have  to  stay  in  bed  a  few  days 
longer,  and  the  supporter  should  be  inseried  before  she  rises.  If  intro- 
duced too  soon  after  the  oj^eration,  and  if  the  patient  is  up,  the  traction 
on  the  fresh  cicatrix  may  stretch  it  and  cause  gaping  of  the  os.  Hence,  if 
this  is  to  be  feai-ed,  astringent  tampons  may  need  to  be  applied  every 
other  day  for  several  weeks  until  the  cicatrix  is  sufficiently  firm. 

If  menstruation  should  unexpectedly  come  on,  as  it  is  quite  liable  to  do 
from  the  ii-ritation,  physical  and  mental,  of  the  operation,  the  sutures 
shovild  be  allowed  to  remain  until  the  flow  has  ceased,  even  if  it  lasts  two 
weeks  or  longer.  That  is,  unless  expulsive  efforts  show  that  the  uterus  is 
trying  to  cast  off  coagula,  when  some  or  all  of  the  stitches  must  be  re- 
moved, and  the  operation  is  a  failure.  If  the  bloody  flow  is  evidently 
menstrual,  it  is  best  not  to  distuib  this  natural  function,  and  the  usual 
vaginal  douches  had  better  be  omitted.  If  there  has  been  considerable 
discharge,  I  occasionally  expose  the  cenix  through  the  speculum  on  the 
eighth  or  tenth  day,  and  if  I  find  it  looking  well  and  the  stitches  not  cut- 
tmg  or  irritating,  I  may  leave  them  in  three  or  four-  days  longer  to  make 
sui-e  of  union.  But  if  the  discharge  is  decidedly  offensive,  it  may  be  a  sign 
of  partial  sloughing  of  the  cervix,  and  an  early  removal  of  the  stitches 
may  be  called  for.  If  the  stitches  are  weU  placed  and  not  too  tight,  they 
can  be  left  in  for  weeks  without  injury,  as  is  necessaiy  when  cervix  and 
perineum  are  operated  on  at  the  same  sitting. 

lieHults  Achieved  hy  Trachelorrhaphij.— The  beneficial  consequences  of 
this  operation,  in  common  with  the  pathological  significance  of  these  lacer- 
ations, have  no  doubt  been  exaggerated  by  the  most  ardent  of  its  advo- 
cates. Unfortunately,  not  every  disease  that  female  flesh  is  heir  to  is  due 
to  a  laceration  of  the  cervix  uteri  or  one  of  its  complications,  and  is  curable 
by  repairing  that  lesion.  Hence,  in  doubtful  cases,  where  the  operation 
was  performed  on  a  more  or  less  presumptive  indication,  either  because 
there  happened  to  be  a  laceration  and  the  prevailing  fashion  required  that 
an  "operation"  of  some  kind  should  be  done,  or  in  cases  where  absolutely 
no  other  cause  for  certain  local  and  general  pains  and  nem'oses  could  be 


INDICATIONS    FOR    TRACHELORRHAPIIY.  471 

found  than,  as  a  last  resort,  a  moderate  cervical  rent,  in  such  cases  a  fail- 
ure to  achieve  the  beneficial  results  expected  undoubtedly  has  often  oc 
curred,  and  still  will  occur.  The  same  may  be  said  of  exijerimental 
measures,  operative  and  otherwise,  in  other  parts  of  the  body.  But  such 
failures  by  no  means  invalidate  the  brilliant  results  which  may  confidently 
be  expected  and  usually  follow  the  operation  where  it  is  clearly  indi- 
cated. Thus,  the  restoration  of  the  cervix  to  its  integrity,  as  well  by  the 
preparatory  curetting,  scarification,  astringent  and  caustic  treatment,  as  by 
the  final  jjlastic  operation,  may  be  relied  upon  to  reheve  and  probably 
cure  the  following  conditions :  Subinvolution  and  hyperplasia  of  the  cervix 
and  the  whole  uterus  (I  have  frequently  seen  this  organ  diminish  from 
three  and  a  half  to  two  and  a  half  inches  within  several  months  after  the 
operation)  ;  cervical  and  corporeal  endometritis  ;  menorrhagia  (nothing 
can  be  more  sure  than  the  cure  of  this  symptom  if  it  depends  on  vegeta- 
tions of  the  endometrium  induced  by  subinvolution  following  a  lacerated 
cervix) ;  chronic  ovarian  congestion  (maintained  by  sympathetic,  perhaps 
lymphatic,  irritation  from  the  eroded  laceration).  A  simultaneous  im- 
provement in  the  management  of  uterine  displacements,  which  occur  so 
frequently  together  with  laceration  of  the  cervix,  and  the  above-named 
conditions,  is  another  beneficial  result  from  the  operation. 

The  benefit  in  the  so-called  neurotic  affections  is  not  so  assured  or  com- 
plete. Still,  Emmet's  testimony  decidedly  favors  this  point,  and  the  cases 
which  I  have  related  in  this  article  prove  that  such  a  thing  as  a  reflex  con- 
nection between  certain  peculiar  distant  neuroses  and  a  cervical  laceration 
does  exist,  and  that  these  neuroses  are  (at  times,  at  least)  curable  by 
trachelorrhaj)hy.  Exactly  how  much  of  this  benefit  is  due  to  moral  and 
how  much  to  physical  influences,  and  in  precisely  what  cases  a  good  result 
may  be  expected,  and  in  which  others  failui-e  will  ensue,  all  this  is  subject 
to  the  uncertainty  peculiar  to  nearly  all  nervous  affections.  Of  this  I  am 
certain,  that  I  have  seen  nervous,  anemic  women,  who  constantl}'  com- 
plained of  "  backache,"  of  bearing  down,  of  pelvic  and  general  neuralgia, 
of  leucorrhea,  loss  of  appetite,  etc.,  gain  flesh  and  color,  lose  not  only  their 
local  but  also  their  general  "  aches,"  and  their  nervousness,  within  several 
months  after  a  successful  trachelorrhaphy.  And  why,  therefore,  should  I 
not  agree  with  them  in  attributing  all  this  imiDrovement  to  the  operation  ? 

One  thing  should  be  remembered,  and  patients  ought  to  be  told  of  it, 
namely,  that  they  must  not  expect  an  immediate  cessation  of  all  theu'  aches 
and  pains  as  soon  as  they  have  left  their  beds  ;  that,  indeed,  for  a  few 
weeks  they  may  still  feel  a  little  weak,  perhaps  even  a  little  worse,  as  a 
direct  result  of  the  operative  manipulations  ;  but  that  the  benefit  is  siu-e  to 
manifest  itself  gradually  in  the  course  of  the  next  three  mouths. 

Now  a  word  about  the  influence  of  trachelorrhai^hrj  on  sterilUij.  It  is  a 
question  under  dispute  as  yet,  whether  the  operation  eums  acquired  sterihty. 
Some  even  go  so  far  as  to  say  that  it  produces  sterility,  but  that  point  I  will 
discuss  hereafter.  I  am  willing  and  able  to  answer  this  question  as  to  whether 
it  cures  sterility,  so  far  as  to  claim,  without  hesitation,  that  when  the  steril- 
ity is  absolute,  and  depends  on  the  presence  of  a  cer\ical  catarrh ;  fui'ther, 


472  GYNECOLOGICAL    OPEEATIONS. 

when  the  stenlity  is  virtual,  that  is,  when  conception  takes  place  but  always 
ends  in  abortion,  either  from  chronic  endometritis  or  from  exposure  of 
the  ovum  to  external  irritating  factors— in  such  cases  trachelon-haphy  un- 
doubtedly cures  sterility.  I  am  unfortunately  not  able  to  prove  this  as- 
sertion satisfactorily  to  others,  I  fear,  since  my  practice  as  an  exclusive 
specialist,  to  whom  many  operative  cases  are  brought  by  general  practi- 
tioners, into  whose  care  they  subsecpently  return,  never  again  to  be  heard 
from  by  the  operator,  prevents  my  being  informed  as  to  whether  pregnancy 
followed  the  operation  or  not.  Therefore  I  am  in  possession  of  but  13 
instances,  out  of  137  operations,  in  which  conception  ensued,  nearly  all  of 
which  occurred  in  patients  of  my  own,  whom  I  subsecxuently  attended  in 
labor.  But  I  am  sure,  judging  from  the  class  of  cases  in  w^hich  I  know' 
conception  to  have  taken  place,  that  the  number  must  be  much  larger, 
quite  as  large,  indeed,  as  the  average  of  conceptions  in  maiTied  women. 
In  a  table  compiled  by  my  assistant,  Dr.  B.  H.  Wells,  I  find  recorded  141 
conceptions  after  1,456  operations.  When  we  consider  the  difficulty  of 
obtaining  such  statistics,  and  the  various  other  factors  influencing  concep- 
tion, the  number  mentioned  is  quite  sufficient  to  estabUsh  the  fact  that 
trachelorrhaphy,  at  all  events,  does  not  prevent  conception. 

Counter-indications  to  Trachelorrhaphy. — So  much  has  ah-eady  been  said 
about  the  indications,  that  a  very  few  words  will  suffice  to  state  when  the 
operation  should  not  be  performed,  even  though  the  laceration  clearly  calls 
for  it.  When  the  uterus  is  more  or  less  fixed  in  the  pelvis  by  adhesions  or 
plastic  exudation  of  so  recent  a  date  as  to  be  painful  to  the  touch,  Avhen,  in 
fact,  the  touch  of  the  examiner  convinces  him  that  the  irritation  accom- 
panying trachelon'haphy  w' ould  be  very  likely  to  rekindle  the  pelvic  inflam- 
mation, then  the  operation  is  positively  counter-indicated.  At  the  same 
time,  there  are  instances  of  old,  insensitive  exudations,  which  have  practi- 
cally become  utterly  passive,  where  the  operation,  carefully  performed,  with 
the  avoidance  of  all  force  or  traction,  is  not  only  advisable  and  safe,  but  act- 
ually beneficial.  I  have  thus  felt  justified  in  operating  three  times  with  the 
happiest  results,  the  stimulus  of  the  operation  (the  slight  depletion,  presence 
of  the  sutures)  and  the  removal  of  the  raw  secreting  surface,  inciting  ab- 
Boi-ption  of  the  exudation.     But  such  cases  must  be  carefully  selected. 

The  operation  is  further  counter-indicated,  for  the  time  being,  if  the 
cervix  has  not  been  thoroughly  prepared,  as  described  in  the  section  on 
Preparatory  Treatment,  and  if  there  is  not  sufficient  time  for  the  wound  to 
heal,  and  the  stitches  to  be  removed  in  due  season  before  the  next  menstrual 
flow.     The  operation  is  absolutely  counter-indicated  during  pregnancy. 

Possible  Dangers  ditking  axd  after  the  Operation. 

TVTiile  all  writers  on  this  subject  have  fully  discussed  and  well-nigh  ex- 
hausted the  various  aspects  of  this  subject,  no  one  seems  to  have  thought 
it  worth  his  while  to  consider  whether  the  operation  is  entirely  free  from 
danger,  and  what  the  accidents  are  w^hich  may  jjos.nbly  happen  during  and 
after  the  operation.     That  such  dangers  do  exist,  and  that  accidents  do 


DANGERS   DURING    TRACHELORRnAPIir.  473 

occasionally  occur,  I  was  fully  aware,  for  I  liacl  had  several  unpleasant  ex- 
periences myself,  and  knew  of  others  in  the  hands  of  other  operators, 
whose  names  are  sufficient  guarantee  that  neither  carelessness  nor  inex- 
perience were  at  fault.  If,  then,  there  were  dangers  and  accidents  in 
Emmet's  operation  which  were  more  or  less  inherent  to  the  nature  of  the 
parts  involved  and  their  proximity  to  large  blood-vessels  and  cavities  and 
to  the  peritoneal  membrane,  and  which,  therefore,  were  not  alwaj-s  to  be 
avoided,  it  was  our  duty  to  recognize  them,  guard  against  them  as  much  as 
possible,  and  not  look  upon  trachelorrhaphy  as  an  always  absolutely  harm- 
less operation.  Of  course,  we  all  know  that  in  the  large  majorit}-  of  cases 
it  is  harmless,  and  no  one  would  think  of  calling  it  a  dangerous  operation, 
or  of  advising  a  patient  to  make  her  will  before  submitting  to  it.  But  as 
no  manipulation,  however  trivial,  of  the  internal  female  genital  organs  can 
be  considered  absolutely  and  always  without  danger  ;  for  even  soundino", 
intra-uterine  applications,  the  curette,  dilatation,  while  usually  pi-actised 
with  impunity,  have  each  had  their  victims — therefore  why  should  not 
trachelorrhaj)hy  have  its  occasional  perils  ?  To  ascertain,  then,  whether 
a  certain  celebrated  authority  was  right  when  he  made  the  dogmatic 
assertion  to  a  gentleman  of  my  acquaintance  that  "in  this  operation  good 
operators  never  meet  with  dangers,  the  bungler  finds  all  the  compU- 
cations,"  I  suggested  to  my  pupil  and  assistant,  Dr.  B.  Hughes  Wells,  to 
use  this  subject  for  his  graduation  thesis.  This  he  did,  and  his  article  was 
published  in  the  American  Journal  of  Obstetrics  for  June,  1884  From  it 
I  draw  the  following  facts  and  figures,  which  not  only  show  that  accidents 
do  occur,  but  that  oj)erators  like  Emmet,  Hunter,  Goodell,  Mann,  Jackson, 
Lusk,  and  Reamy,  certainly  no  "  bunglers,"  have  each  one  or  more  such  to 
record.     What  these  accidents  are  I  shall  now  proceed  to  state. 

Dangers  during  the  Operation. 

1.  Primary  Hemorrhage. — I  have  already  spoken  of  this  occuiTence 
while  describing  the  operation,  and  also  of  the  means  of  checking  it, 
either  by  hot  sponges,  if  it  is  pai-enchymatous,  or  by  deep  sutures  thi-ough 
the  upper  angle  of  the  wound,  and  by  early  twisting  of  all  the  sutures  on 
the  bleeding  side,  if  it  is  diffuse  or  an  artery  is  wounded.  I  need  there- 
fore not  enlarge  upon  this  subject  again. 

2.  Too  Thorough  Denudation. — This  occurrence  has  also  been  refen-ed 
to,  and  can  scarcely  be  called  either  an  accident  or  a  danger,  since  it  is 
solely  the  fault  of  the  operator.  It  is  easily  avoided  by  carefully  tracing 
out  the  hmits  of  the  flaps  to  be  excised,  and  by  remembering  when  be- 
ginning the  operation  that  it  is  always  easy  to  remove  more  tissue,  but 
that,  once  removed,  it  cannot  be  replaced.  The  consequence  of  too  thor- 
ough denudation  is  either  the  wounding  of  arterial  twigs,  or  the  extension 
of  the  wound  on  the  vaginal  mucous  membrane  proper,  which  results  in 
puckering  when  the  stitches  are  twisted.  But  a  much  more  serious  con- 
sequence ensues  when  the  denudation  is  carried  too  far  inward  towai-d  the 
cervical  canal,  leaving  too  small  an  external  os,  and  too  narrow  a  canal. 


474  GYIN^ECOLOGICAL    OPERATIONS. 

Here  sterility  and  even  dysmenorrhea  may  ultimately  ensue,  and  require 
the  dilatation  or  even  incision  of  the  constricted  j^art.  The  employment 
of  a  o-lass  ping  to  prevent  such  excessive  contraction  or  adhesion  in  cer- 
tain cases  has  been  ah-eady  referred  to. 

Dangers  after  the  Operation. 

1.  Sloughing  of  cervical  tissue  will  take  place  during  the  week  following 
the  operation  if  too  many  stitches  were  introduced,  if  they  were  drawn  too 
tightly,  and  particulai'ly  if  they  chance  to  cross  each  other  so  as  to  pro- 
duce strangulation  of  the  intervening  tissue.  A  pallid  appearance  of  the 
cervix,  or  of  portions  of  it,  most  commonly  of  the  Ups  of  the  prospective 
OS,  immediately  after  the  sutiu'es  have  been  twisted,  will  foreshadow  this 
occurrence,  and  demand  loosening  of  the  offending  stitches.  An  offensive, 
sanguineo-purulent  discharge  several  days  after  the  ojDeration  may  also  in- 
dicate the  occurrence  of  sloughing,  and  call  for  a  specular  examination  to 
ascertain  the  facts.  If  found  to  be  the  case,  the  sutures  at  fault  should  be 
removed,  as  their  presence  can  only  do  more  harm,  and  the  chance  of 
good  union  is  at  the  best  doubtful.  In  puffy,  unhealthy  tissues  sloughing 
may  occur  and  entail  a  failure  of  union,  without  the  operator's  being  to 
blame. 

2.  Menstruation  immediately  following  the  operation  has  not,  in  my  ex- 
perience, proved  an  obstacle  to  good  union,  and  merely  calls  for  non- 
interference with  the  stitches  until  the  flow  has  ceased.  I  have  already 
sufficiently  discussed  this  j)oint  elsewhere. 

3.  Secondary  hemorrhage,  occurring  at  any  time  between  the  close  of 
the  operation  and  the  removal  of  the  sutui-es,  is  a  rare  accident,  and  I  had 
performed  fully  one  hundr-ed  operations  before  it  happened  to  me.  Then, 
strange  to  say,  I  had  two  cases  of  it  in  the  same  week,  one,  particularly,  so 
profuse  as  to  alarm  me.  In  both  the  hemoiThage  was  arterial  and  came 
on  the  fifth  day.  In  the  first,  a  private  case,  I  hastUy  removed  the  clots 
thi'ough  the  Sims,  intending  to  search  for  and  if  possible  compress  the 
bleeding  spot  with  long  artery  forceps  ;  but  I  could  merely  see  that  the  blood 
flowed  in  a  stream  from  the  external  os.  Had  I  had  my  instruments  with 
me,  I  should  have  at  once  passed  a  long  needle  armed  with  thick  wire 
deeply  through  the  centre  of  the  cervix  and  have  carried  the  wire  around 
the  crown  of  the  cervix  and  twisted  it  in  front ;  in  this  way  the  whole 
cerrix  would  have  been  compressed.  But  in  the  absence  of  the  instm- 
ments  I  could  do  nothing  but  rapidly  pack  the  vagina  full  of  flat  disk 
tampons,  which  I  had  prepared  before  beginning  the  examination,  and  the 
first  of  which  I  covered  with  powdered  alum.  Fortunately  the  hemorrhage 
was  arrested,  the  tampons  were  reinserted  eveiy  second  day  untU  the 
fourteenth  day  after  the  operation,  Avhen,  no  fui'ther  hemon-hage  havmo- 
occurred,  the  stitches  were  removed  and  union  was  found  perfect. 

In  the  second  case,  which  occurred  in  the  hospital,  and  was  one  of  com- 
bmed  trachelorrhaphy  and  perineorrhaphy,  the  hemorrhage  was  not  quite 
so  alarming,  but  veiy  persistent,  and  failed  to  respond  to  hot  alum  douches ; 


POSSIBLE    EVIL    EESULTS    AFTER   TRACHELORRHAPHY.       475 

finally  injections  of  ice-water  and  -vinegar,  equal  parts,  checked  it.  Two 
days  later  I  removed  the  oftensive  coagula,  with  which  the  vagina  was 
filled,  with  my  finger,  and  made  another  vinegar  injection,  and  the  hemor- 
rhage did  not  return.  In  this  case  the  simultaneous  closure  of  the  peri- 
neum precluded  the  use  of  the  speculum  and  tamponade.  Here  also  union 
of  cervix  and  perineum  was  subsequently  found  perfect,  in  spite  of  all  the 
handling.  I  have  seen  several  cases  since  of  slight  oozing  during  the  first 
forty-eight  hours,  which  have  always  readily  yielded  to  the  hot  alum 
douche.  Of  course,  menstruation  should  not  be  confounded  with  sec- 
ondary hemorrhage,  and  can  easily  be  distinguished  by  the  dark  color  of 
menstrual  blood. 

Emmet  has  had  one  very  severe  case  of  repeated  secondary  hemoi'- 
rhage,  which  finally  required  the  secondary  suture.  Fallen  and  Goodell 
each  have  had  one  ;  and  doubtless  others  have  occurred  which  have  not 
been  published. 

Of  course  the  secondary  suture,  v/hen  it  encircles  the  whole  cervix, 
should  neither  be  twisted  so  tightly  as  to  strangulate  the  organ  nor  be  left 
in  so  long  as  to  cause  sloughing ;  forty-eight  hours  would  probably  be  the 
longest  time  which  it  would  be  safe  to  leave  the  suture  unwatched  or  un- 
disturbed. If  the  hemoi'rhage  is  seen  to  come  from  one  side  of  the  cervix 
only,  of  course  only  that  half  need  be  enclosed  in  the  wire  ligature. 

Pelvic  Cellulitis  and  Peritonitis. — So  little  reference  is  made  in  the  books 
to  the  danger  of  this  accident  following  traction  on  the  cerdx  during 
trachelorrhaphy,  that  the  reader  will  be  sui-prised,  as  I  was,  to  find  the 
result  of  Dr.  Wells'  search  through  recent  journal-literature  and  private 
sources  to  be  a  total  of  43  cases  (34  cellulitis,  9  peritonitis)  with  6  deaths, 
occurring  in  the  practices  of  Drs.  Hunter  (4  with  1  death),  Goodell  (7  with  3 
deaths),  Mann  (3),  Mundc  (4  with  2  deaths),  Emmet  (1),  Reamy  (6),  Jack- 
son (3),  and  some  other  operators  of  equal  prominence.  The  cause  of 
death  was  in  all  cases  general  peritonitis.  My  two  cases  occurred  in  the 
hospital,  and  I  incline  to  the  opinion  that  septic  infection  was  the  cause  of 
the  peritonitis  rather  than  traumatism,  since  in  the  first  case  the  peritonitis 
did  not  begin  until  the  tenth  day,  when  the  stitches  had  already  been  re- 
moved and  perfect  union  was  found  ;  as  it  was  a  case  of  prolapsus,  abso- 
lutely no  traction  was  practised  on  the  cervix  during  the  operation.  One  of 
my  cases  of  cellulitis  was  seen  in  consultation,  and  is  therefore  not  j^roi^erly 
my  own  case.  Here  we  have  43  cases  of  pelvic  inflamnKation  with  6  deaths 
in  the  practices  of  15  gentlemen  of  the  highest  reputation  as  gynecologists  ! 
surely  sufficient  to  lead  us  to  observe  every  precaution  against  accident, 
even  in  .this  comparatively  trifling  operation. 

Possible  Evil  Results  after  the  Operation. 

1.  The  evil  result  which  is  most  likely  to  occur  is  i\\e  failure  of  the  lips 
of  the  ivound  to  unite,  either  wholly  or  in  part. 

The  causes  of  such  failm-e  are  various  :  Imperfect  preparation  of  the 
cervix,  leaving  it  in  a  pulpy,  soft,  highly  hyperemic  condition  ;  imperfect 


476  GYNECOLOGICAL    OPERATION'S. 

denudation  and  coaj^tation  ;  want  of  cleanliness  of  instruments  and 
sponges  ;  too  few  or  too  many,  crossed,  or  too  tightly  twisted,  sutures ; 
carelessness  on  the  part  of  the  j^atient  in  rising  too  soon,  or  straining  at 
stool,  or  of  the  nurse  (inserting  the  douche-tube  too  far)  ;  advent  of  men- 
struation, resulting  in  the  retention  of  coagula  in,  and  subsequent  forci- 
ble expulsion  from,  the  uterus  ;  septic  infection,  or  rather  hospitalism  ;  and 
finally,  general  debility,  producing  an  anemic,  aplastic  state  of  the  blood. 

Some  of  these  causes  of  failure  will  thus  be  seen  to  be  attributable  to 
the  operator,  others  to  the  patient,  and  others  again  to  atmospheric  and 
accidental  factors.  Those  attributable  to  operator  and  patient  can  generally 
be  guarded  against  and  avoided  ;  it  is  but  necessai'y  to  refer  to  each  one 
to  at  once  see  its  antidote. 

The  deleterious  influence  of  hospitalism  on  the  healing  of  plastic  wounds 
can  be  counteracted  only  by  the  most  scrupulous  antisepsis  or  by  not  op- 
erating in  the  hospital  when  such  a  tendency  seems  to  prevail.  I  have  had 
several  failures  both  of  cervix  and  perineum  ojjerations  in  the  hospital, 
after  a  number  of  successful  operations,  when  I  could  positively  find  no 
other  cause  for  non-union  than  the  evident  reluctance  of  the  tissues  to 
unite,  a  reluctance  which  in  two  cases  of  perineorrhaphy  was,  I  now  think, 
due  to  general  mal-nutrition  of  the  jiatient  ;  but  in  the  cervix  cases  the  fail- 
ure could  be  attributed  to  no  such  cause.    Here  also  the  remedy  is  obvious. 

The  proportion  of  failures  requii'ing  a  secondary  operation  is  about 
eight  per  cent.  I  had  10  faihu-es  out  of  137  operations.  "Wells'  statistics 
show  637  operations  with  44  failures,  or  about  6.90  per  cent.,  but  this  pev- 
centage  is  rather  too  low,  as  one  operator  had  only  2  failures  out  of  110 
operations,  a  result  so  much  better  than  even  Emmet  claims,  that  it  must 
be  considered  exceptional. 

Not  every  failure  calls  for  a  secondary  operation,  since  partial  union 
often  ultimately  makes  a  very  good  result  by  cicatricial  contraction  ;  and 
if  the  operation  was  originally  called  for  by  ectropium  chiefly,  a  result 
which  leaves  the  cervix  perfectly,  if  unevenly,  healed,  may  answer  the  re- 
quirements of  that  case.  If  the  indication  was  to  remove  all  cicatricial 
tissue,  why  then,  of  course,  nothing  but  entire  absence  of  such  tissue  can 
be  considered  satisfactory,  and  the  operation  must  be  repeated.  If  a 
secondary  operation  is  required,  it  should  not  be  performed  until  all  the 
lesions  of  the  first  attempt  have  thoroughly  healed,  and  the  cervix  is  in 
perfect  condition  for  plastic  repair. 

2.  A  f ui-ther  evil  result  which  may  follow  trachelorrhaphy  is  the  produc- 
tion of  sterility.  This  supposed  consequence  of  the  operation  has  of  late 
been  the  subject  of  some  discussion,  several  operators  even  claiming,  be- 
cause so  few  cases  are  reported  of  pregnancy  after  the  operation,  that  it 
prevents  conception.  I  have  ah-eady  pointed  out,  while  speaking  of  the 
good  efi"ects  of  tracheloiThaphy,  why  it  is  next  to  impossible  for  specialists, 
who  do  the  large  majority  of  these  plastic  operations,  to  keep  track  of  the 
subsequent  history  of  the  large  number  of  patients  who  are  brought  to 
them  for  advice  or  operation  by  other  practitioners.  Hence  the  failure  of 
these  specialists  to  report  many  cases  of  conception  after  trachelorrhaphy 


POSSIBLE    EVIL    EESULTS    AFTER    TRACHELORRHAPHY.       477 

can  by  no  means  be  assumed  as  an  e%ddence  that  the  operation  produces  or 
is  followed  by  sterility.  Such  an  assumj^tion  is  as  absurd  as  it  would  be 
to  assert  that  perineorrhaphy  entails  sterility,  because  it  is  next  to  impossi- 
ble to  find  statistics  of  subsequent  pregnancy  when  searching  for  evidences 
of  relaceration  of  the  perineum. 

It  is  to  the  general  practitioners  that  we  must  look  for  information  on 
this  point.  While  it  cannot  perhaps  be  claimed,  on  the  basis  of  the  141 
pregnancies  recorded  as  having  followed  the  operation  in  the  table  of  1,456 
cases  comiDiled  by  Wells,  that  trachelorrhaphy  actually  cures  sterility,  it 
certainly  cannot  be  maintained  that  these  same  figures  prove  that  the 
operation  entails  sterility. 

Of  the  1,456  cases  in  W^ells'  table,  only  126  were  available,  according  to 
him,  for  the  purpose  of  a  statistical  deduction  of  the  ratio  of  conception, 
since  they  alone  comprised  all  the  cases  of  several  operators  who  keiDt  sight 
of  them  and  recorded  subsequent  impregnation.  Of  these  126  women,  32, 
or  25.4  per  cent.,  conceived  after  the  operation,  surely  a  very  fair  pro- 
portion, when  we  consider  all  the  other  factors  necessary  to  concej)tion. 

The  large  number  of  pregnancies  recorded,  in  spite  of  the  imperfect 
reports  of  the  results  of  the  operation,  undoubtedly  shows  that  pregnancy, 
to  say  the  least,  frequently  occurs  after  trachelorrhaphy. 

I  cannot  but  think  that  those  operators  who  find  sterility  following  their 
operations  have  but  themselves  and  their  methods  io  blame  ;  if  they 
neglect  the  caution  which  I  have  been  careful  to  emphasize  in  these  images, 
and  make  the  external  os  too  small,  losing  sight  of  the  inevitable  cicatri- 
cial contraction  which  follows  sooner  or  later,  why,  they  surely  cannot  cen- 
sure the  operation,  but  only  their  own  awkwardness,  if  temporary  sterihty 
happens  to  ensue. 

3.  Ohstruction  to  a  future  labor  from  cicatricial  tissue,  and 

4.  Relaceration  at  a  subsequent  labor. 

The  same  reasons  which  prevent  my  giving  a  large  array  of  figures  in 
proof  of  the  fact  that  tracheloriiiaphy  does  not  produce  sterility,  apply  to 
these  two  possible  results  of  the  operation. 

So  far  as  my  own  experience  goes  in  the  matter,  I  feel  confident  that 
the  dilatation  of  the  os  at  a  future  labor  is  very  little,  if  any,  interfered 
with  by  such  cicatricial  tissue  as  may  remain  from  the  ojDeration.  I  have  had 
occasion  to  examine  quite  a  large  number  of  cervices  upon  whom  trache- 
lorraphy  had  been  performed  by  myself  and  others  one  or  more  yeai's, 
more  or  less,  previously,  and  I  have  invariably  noticed  the  singular  absence 
of  cicatricial  induration  or  nodules  in  those  cases  where  good  smooth 
union  had  been  achieved.  The  cicatrix  was,  in  fact,  usually  scarcely  recog- 
nizable either  by  sight  or  touch.  It  seems  to  melt  away  with  unusual  ra- 
pidity in  the  cervix.  All  observers  who  have  had  opiDortunity  to  notice 
agree  that  labor  is  in  no  way  retarded. 

As  regards  relaceration,  in  the  few  cases  which  I  have  had  occasion  to 
follow  through  subsequent  labors,  none  but  the  very  least  nicking  of  the  lip 
of  the  OS  has  occurred,  and  the  testimony  of  other  operators  is  similar,  the 
universal   opinion  being  that  laceration  is  no  more  likely  to  occur  after 


478  GYNECOLOGICAL    OPERATIONS. 

traclielorrhapliy  than  in  a  primipara.  Wells'  statistics  show  that  of  the  77 
cases  where  the  condition  of  the  cervix  was  noted  after  labor,  62,  or  eighty 
per  cent.,  were  not  relacerated,  while  of  the  remaining  15,  8  were  but 
shghtly  torn. 

Possible  Results  if  Trachelokrhapht  is  not  Peefokmed. 

Having  now  disposed  of  all  that  pertains  to  the  significance  of  lacera- 
tion of  the  cervix,  to  its  treatment  and  cure,  and  the  advantages  and  possi- 
ble disadvantages  of  the  radical  operation,  it  but  remains  for  me  to  discuss 
the  question  as  to  what  will  be  the  probable  or  possible  result  if  the  lacera- 
tion is  merely  treated  palliatively  and  is  not  cured  by  operation. 

The  answer  is  a  simple  one,  and  has  already  been  given  in  a  measure 
under  Prognosis. 

If  the  pathological  changes  in  the  cervix,  uterus,  and  adnexa  are  of 
moderate  degree,  and  the  symptoms  correspondingly  slight,  palliative 
treatment  will  probably  enable  the  patient  to  exist  in  comparative  comfort 
until  the  menopause  and  its  succeeding  years  bring  rest  to  her  sexual  or- 
gans, and  remove  them  from  their  active  sphere  for  good  and  evil.  But 
it  should  be  remembered  that  treatment  will  need  to  be  more  or  less  con- 
tinual, and  that  it  is  the  exception  to  see  palliative  measures  in  these  cases 
followed  hy  permanent  impro"<'ement. 

If  the  pathological  conditions  and  dependent  symptoms  are  of  an  ag- 
gravated nature,  such  as  are  characteristic  of  large,  raw  lacerations  of  the 
third  degree,  with  subinvolution  and  hyperplasia,  menorrhagia,  etc.,  then 
palHative  means  give  but  slight  relief,  and  the  patient  will  gradually  sink 
into  a  state  of  chronic  invalidism,  from  which,  if  allowed  to  continue  too 
long,  nothing,  not  even  the  vaunted  trachelorrhaphy,  can  save  her.  Of 
course,  eventually,  the  menojDause  will  here  also  bring  a  certain  amount  of 
reUef,  but  it  will  probably  take  years  to  recover  from  the  physical  and 
nervous  prostration  jDreceding  that  period. 

Finally,  the  undoubted  predisposition  to  malignant  degeneration  of 
the  raw,  hyperplastic  cervix  should  be  carefully  borne  in  mind,  a  result 
which  may  happen  at  any  time  until  the  erosion  is  permanently  healed. 

In  conclusion,  it  cannot  be  denied  that  occasionally  a  case  of  even 
severe  chronic  laceration  heals  spontaneously  and  all  the  symptoms  disap- 
pear permanently  without  treatment.  But  this  event  is  so  rare  as  to  be 
IDOor  consolation. 


OPERATIONS   FOR   LACERATED   PERINEUM, 
RECTOCELE,  CYSTOCELE,  AND  PROLAPSUS  OF  THE  UTERUS  AND  VAGINA. 

I  have  included  these  several  operations  under  one  heading  because 
the  accident  which  produces  the  first  lesion  is  usually  the  starting-point 
and  more  or  less  directly  the  cause  of  the  others,  and  because  the  differ- 
ent operations  for  the  cure  of  these  lesions  are  all  based  on  the  same 
fundamental  principle,  the  narrowing  of  the  vaginal  tube  and  its  orifice. 


SECONDARY    OPEEATION    FOR    LACERATED    PERINEUM.       479 


The  Secondaey  Operation  for  Lacerated  Perineum. 

Varieties  and  Degrees  of  Laceration  of  the  Perineum. — There  ai-e  thi-ee 
varieties  of  laceration  of  the  perineum  :  the  imrtial,  to  the  sphincter  ani ; 
the  comj^lete,  through  the  sphincter  ani  and  more  or  less  up  the  recto- 
vaginal septum  ;  and  the  central,  or  perforation  of  the  perineum  with 
fourchette  and  sphincter  ani  intact. 

The  partial  and  the  complete  laceration  may  be  divided  into  three  de- 
grees, according  to  the  depth  of  the  rent.  Partial,  first  degree,  is  merely 
a  nick  of  the  fourchette  down  to  the  bottom  or  slightly  including  the  edge 
of  the  navicular  fossa  ;  second  degree,  midway  to  the  sphincter  ani ;  and 
third  degree,  to  the  very  edge  of  the  sphincter  ani.  Complete,  first  degi*ee, 
through  the  anterior  fibres  of  the  sphincter ;  second  degree,  completely 
through  the  sphincter  and  one  to  two  inches  up  the  recto-vaginal  septum, 
but  not  through  the  inner  sphincter ;  and  third  degree,  through  the  inner, 
or  second  sphincter  ani. 


Fig.  255.— Outline  Diagram  Rhowing 
Degrees  of  Partial  Rupture  of  Perineum. 
V,  vagina ;  P,  perineum ;  R,  rectum  (F. 
F.  M.). 


Fig.  256. — Outline  Dia^am  showing  Degrees  of 
Complete  Rupture  of  Perineum.  S,  sphincter;  3, 
shows  laceration  at  internal  sphincter  (P.  F.  il.). 


I  have  thought  it  best  to  make  this,  perhaps  arbitrary,  division  because 
the  pathological  significance  and  gravity  of  symptoms  differs  and  increases 
so  much  with  each  degree  of  the  lesion,  and  because  complete  rupture  pro- 
duces distress  so  entirely  out  of  j^roportion  to  that  caused  by  partial  lacer- 
ation, that  the  two  varieties  ought,  at  least,  to  be  classified  separately. 
Except  as  to  extent  of  surface,  the  methods  of  operation  in  each  variety, 
however,  differ  but  httle.  Not  unfrequently  in  partial  ruptures  the  rent 
separates  at  the  sphincter  and  extends  like  an  inverted  f]  on  either  side  of 
that  muscle. 

Frequence/. — Kuptures  of  the  perineum  of  the  partial  variety  and  first 
degree  probably  occur  in  three-fourths  of  all  primipame.  If  a  woman  has 
escaped  a  laceration  of  the  fourchette  in  her  first  labor,  slie  probably  will 
not  undergo  it  at  a  subsequent  confinement.  Still,  occasionally  the  peri- 
neum remains  absolutely  intact  at  the  first  labor,  and  an  unusually  large 
size  of  the  child,  a  very  rapid  or  instrumental  labor,  or  carelessness,  may 
at  a  subsequent  labor  cause  a  laceration. 


430  GYNECOLOGICAL    OPERATIONS. 

Partial  laceration  of  the  second  and  tldrd  degrees  probably  occurs  in 
about  one-quarter  of  all  primiparae. 

In  what' proportion  complete  laceration  of  one  degree  or  the  other  oc- 
curs, I  am  unable  to  say.  I  have  seen  many  such  cases,  but  as  all  but  two 
were  chronic  cases  I  cannot  form  a  fair  estimate  as  to  their  frequency. 
Fortunately  they  are  infinitely  more  rare  than  the  partial  ruptures.  While 
the  latter  are  usually  caused  by  the  size  or  rapid  passage  of  the  child's 
head  or  shoulders,  the  complete  ruptures  are  generally  caused  by  the 
precipitous  extraction  of  the  head  with  forceps  in  the  hands  of  a  careless 
or  unskilled  operator.  The  partial  ruptures,  therefore,  can  often  be 
avoided  ;  the  complete  should  really  never  occur,  except  under  quite  un- 
usually difficult  conditions. 

Anatomical  Relations  and  Diagnosis.— In  partial  lacerations  the  mucous 
membrane  of  the  vaginal  orifice,  the  muscular  aponeurosis  constituting 
the  so-called  "perineal  body"  (transversus  perinei  superficialis  and  pro- 
fundus, constrictor  cunni),  the  superficial  fascia,  the  subcutaneous  cellular 
tissue,  and  lastly  the  skin  (occasionally  the  skin  cracks  first)  are  torn,  but 
the  recto-vaginal  septum  remains  intact.  Instead  of  the  vagina  terminat- 
ing at  the  fourchette,  it  now  ends  at  that  point  of  the  external  skin  at 
which  the  rent  stops  ;  the  vulvar  fissure  is  lengthened  backward.  When 
cicati-ization  takes  place,  the  h}T^)erplastic  mucous  membrane  of  the  poste- 
rior vaginal  wall  is  often  drawn  down  and  out  by  the  contraction  of  the 
cicatrix,  which  separates  the  labia  majora  and  causes  the  vulvar  cleft  and, 
beyond  it,  the  vaginal  orifice  to  gape.  If  the  rent  extended  some  distance 
up  into  the  vagina,  which  is  frequently  the  case,  or  if  it  was  slightly  lateral 
instead  of,  as  usual,  in  the  median  line,  distortion  of  the  posterior  vaginal 
wall  and  remnant  of  perineum  by  cicatrization  may  take  place.  The  size  and 
shape  of  the  cicatrix  is  recognized  by  the  shiny,  smooth  character  of  the 
vaginal  orifice,  and  by  the  fringes  of  tissue  which  often  oi*nament  its  borders. 
In  women  who  have  had  a  number  of  very  severe,  protracted  labors,  with 
enormous  overdistention  of  the  perineum,  a  condition  of  that  body  is  not 
infrequently  met  with  which  practically  corresponds  to  its  destmction  by 
laceration.  That  is,  the  overdistended  perineal  muscles  never  regain  their 
tone,  the  fascia  remains  flabby  and  pendulous,  and  the  perineum  might  as 
well  be  absent  for  all  the  support  it  gives  to  the  vaginal  and  rectal  walls. 
This  paralysis  of  the  perineum  has  by  some  gynecologists,  perhaps  with 
reason,  been  attributed  to  a  "sundering"  of  the  muscles  from  their  central 
aponeurosis,  leaving  only  the  skin  and  mucous  membrane  without  and 
within,  with  perhaps  some  cellular  tissue  and  fat,  to  represent  the  firm, 
muscular,  elastic  perineum  of  health.  Veiy  commonly  the  vaginal  walls 
participate  in  this  relaxation. 

The  appearance  of  a  complete  rupture  is  even  more  striking  and  char- 
acteristic than  that  of  a  partial  rent.  According  to  the  length  of  the  lac- 
eration of  the  recto-vaginal  septum,  a  more  or  less  deep  notch  is  seen  in 
place  of  the  anterior  arch  of  the  sphincter  ani,  through  which  notch,  if  the 
rent  is  a  deep  one,  the  scarlet  mucous  membrane  of  the  rectum  often  pro- 
trudes.    This  notch  is  generally  in  the  median  line,  although  cicatricial 


SECONDARY    OPERATION    FOR    LACERATED    PERINEOI.       481 

contraction  may  occasionally  draw  it  slightly  to  one  side.  The  torn  ends 
of  the  sjDhincter  are  imbedded  in  and  covered  by  shiny  cicatricial  tissue  at 
either  side  of  the  gaping  anus,  the  rugous  margin  of  which,  instead  of 
radiating  toward  the  central  orifice  as  in  health,  is  more  or  less  horizontal, 
even  somewhat  everted  if  cicatricial  retraction  has  been  very  marked. 
Thick  rugous  folds  of  vaginal  mucous  membrane,  often  bound  down 
laterally  by  flat  cicatrices,  the  result  of  sloughing  after  labor,  may  overlap 
the  edges  of  the  rent  in  the  lesser  degrees ;  if  the  fissure  extends  up  to  or 
above  the  internal  sphincter,  its  edges  are  generally  sharp  and  thin. 

Occasionally  an  attempt  at  primary  union  is  shown  by  a  band  of  tissue, 
uniting  the  edges  of  the  fissure,  leaving  a  recto-vaginal  fistula  above. 
Large,  deep  cicatricial  adhesions  often  extend  up  into  the  vagina  on  one 
side  or  the  other  (usually  the  result  of  fissures  made  by  the  forceps), 
perhaps  dragging  down,  fixing,  or  distorting  the  uterus,  and  attaching 
the  vaginal  walls  to  the  pelvic  fascia. 

It  is  evident  that  in  large  lacerations  (partial  and  complete)  with  abun- 
dant thick  cicatricial  tissue  the  latter  itself  sej)arates  the  labia  and  causes 
the  vaginal  orifice  to  gape. 

From  the  above  descrij)tion  the  diagnosis  between  partial  and  complete 
laceration  can  easily  be  made,  and  the  extent  of  the  injury  ascertained,  if 
need  be,  by  passing  the  index-finger  into  the  rectum  and  the  thumb  into 
the  vagina,  when  the  exact  amount  of  remaining  perineal  tissue  is  gi'asped. 

In  deciding  upon  the  extent  of  the  injury,  the  possibility  of  approxi- 
mating the  edges  of  the  rent,  or  of  the  torn  sphincter  ani  should  be  ascer- 
tained with  a  view  to  a  restorative  operation. 

The  existence  of  a  central  laceration  is  easily  detected  :  an  irregular 
opening  with  cicatrized  borders  communicates  Avith  the  vaginal,  canal  gen- 
erally but  a  short  distance  above  the  entrance,  forming  a  perineo-vaginal 
fistula. 

Pathological  Results  of  Laceration  of  the  Perineum. — The  most  fre- 
quent and  natural  result  of  the  destruction  of  the  strong,  elastic  combina- 
tion of  muscles,  fascia,  skin,  and  mucous  membrane,  knoAvn  as  the  "  peri- 
neal body"  or  " triangle,"  is  the  gradual  descent  of  the  posterior  and 
anterior  vaginal  walls,  which  are  supported  by  the  perineum,  and  secondarily 
of  the  uterus,  which  is  in  a  measui-e  sustained  by  the  vaginal  walls.  Together 
with  the  vaginal  walls  comes  down  the  contiguous  portion  of  the  rectum — 
rectocele — and  of  the  bladder — cystocele — either  or  both,  sometimes  the 
one,  at  other  times  the  other  taking  the  lead.  There  are  two  gradations 
by  which  this  descent  of  vagina  and  uterus  takes  place. 

1.  The  loss  of  the  j)erineum  leaves  the  posterior  vaginal  wall  uusus- 
tained,  it  gradually  slides  down,  relaxed  and  subinvoluted  as  it  generally 
is  after  a  severe  labor  ;  in  consequence  the  uterus,  deprived  of  its  support 
little  by  little,  partly  tips,  partly  is  drawn  backward  and  downward,  and 
enters  into  the  first  stage  of  prolapsus  and  one  of  the  three  stages  of  re- 
troversion. Then  ultimately,  but  not  necessarily,  the  anterior  vaginal 
wall,  which  has  all  this  time  steadily  resisted  the  absence  of  its  natural 
support  in  the  erect  position,  the  lower  part  of  the  posterior  vaginal  wall 
31 


482 


GYNECOLOGICAL    OPERATIONS. 


and  perineum,  is  forced  down  by  the  varying  pressure  of  the  elastic 
bladder,  and  with  it  drags  down  the  ah-eady  partly  prolapsed  uterus.  And 
we  thus  have  1,  rectocele  ;  2,  descensus  and  retroversion  ;  3,  cystocele  ;  and 

4,  full  descensus  uteri. 

2.  The  other  series  of  steps 
by  which  the  same  result  is  ob- 
tained, begins  with  the  anterior 
wall,  which,  deprived  of  its  sup- 
port sags  down,  together  with  the 
adjacent  portion  of  the  bladder, 
and  drags  down  the  uterus  with 
it.  "We  then  have  cystocele  and 
descensus,  with  ante  version  as 
yet,  not  retrodisplacement  of  the 
uterus.  Then,  eventually,  the 
posterior  vaginal  wall  begins  to 
prolapse,  the  uterus  is  dragged 
down  still  more,  and  the  fundus 
retires  in  the  only  direction 
where  it  has  room,  namely,  back- 
ward. "We  thus  have  precisely 
the  same  result  as  in  the  first 
series.  It  must  not  be  supposed, 
however,  that  we  invariably  have  all  these  sequences  of  a  lacerated  perineum 
in  the  same  case,  or  indeed  that  we  must  inevitably  have  any  of  them.  On 
the  contrary,  most  frequently  we  find  only  a  rectocele  with  retroversion 
and  descensus  ;  next,  a  cystocele  with  descensus  of  the  uterus  ;  with  equal 
frequency,  perhaps,  a  rectocele  and  cystocele  with  descensus  and  retrover- 
sion ;  and  most  rarely  a  de- 
scensus of  the  fii'st  or  second 
degree  without  prolapsus  of 
the  vaginal  walls.  In  the 
latter  instance  the  abnormal 
weight  of  the  uterus  (gen- 
erally due  to  subinvolution) 
simply  tires  out  its  liga- 
ments and  allows  it  gradu- 
ally to  sink  down  until  the 
cervix  touches  the  floor  of 
the  pelvis,  without  there 
being  any  involvement  of 
the  vaginal  walls.  It  is  sim- 
ply in  the  one  case  a  drag- 
ging from  below,  in  the 
other  a  sinking  from  above. 


Fig.  257. — Normal  Relations  of  Female  Pelvic  Organs, 
Bhowing  Perineum  Supporting  Vagina,  Bladder,  and  Rec- 
tum (P.  F.  M.). 


Fig.  258. — Absence  of  Perineum,  showing  Bladder  and  Vagina 
without  Support.  Dotted  line  Bhows  normal  posterior  vaginal 
wall  and  perineuui  (P.  F.  M.). 


Why  in  one  case  a  rectocele,  in  the  other  a 
cystocele,  and  in  the  third  a  combination  of  these  two  conditions  shotdd 
be  the  predominating  feature,  it  is  not  always  easy  to  determine. 


SECONDAEY    OPEEATIOK    FOR    LACERATED    PERINEU3I.       483 

As  a  rule,  it  is  safe  to  assume  that  the  deeper  the  rent  the  more  certain 
and  distressing  the  symj^toms,  chiefly  the  descensus.  But  cases  are 
occasionally  met  with  where  even  a  partial  laceration  of  the  third  degree  is 
unattended,  even  after  many  years,  by  the  least  falling  of  either  vagina  or 
uterus.  This  anomaly  can  perhaps  be  explained  by  an  exceptional  firm- 
ness of  the  vaginal  walls  and  suspensory  ligaments,  as  well  as  by  thorough 
involution  of  the  uterus.  Stranger  still,  in  complete  ruptui-e,  in  even 
the  worst  cases,  prolapse  of  vagina  and  uterus  is  rather  the  exception, 
although  prolapse  of  the  rectum  is  a  common  feature.  This  aj)parent  im- 
probability can  be  very  plausibly  explained  by  the  fact  that  iia  these  very 
bad  ruptures  there  has  usually  been  some  plastic  infiltration  into  the  peri- 
metran  cellidar  tissue  or  the  broad  ligaments,  or  some  cicatricial  indura- 
tion of  the  vaginal  walls,  which  prevents  descensus.  Besides,  the  cica- 
tricial retraction  of  the  sphincter  aui  and  posterior  vaginal  wall  may  act  as 
a  sort  of  barrier  to  a  protrusion  of  the  vagina. 

Other  pathological  results,  besides  prolapsus  of  the  vagina  and  uterus, 
which  are  entailed  with  more  or  less  uniformity  by  a  lacerated  perineum 
are  :  Subinvolution  of  the  vaginal  walls,  a  gaping  of  the  vaginal  orifice, 
and,  as  a  consequence  of  the  latter,  leucorrhea,  entrance  of  air  into  the 
vagina,  dyspareunia,  and  sterility. 

Subinvolution  of  the  vaginal  ivalls  is  but  the  natural  result  of  the  inter- 
ference with  circulation  and  nutrition  of  those  parts  induced  by  the  lacer- 
ation and  the  efforts  of  nature  to  repair  it  by  granulation  and  cicatrization. 
The  subinvolution  manifests  itself  by  the  thick,  redundant  condition  of 
the  vaginal  wall,  by  a  hypertrophy  of  the  normal  rugae,  and  a  protrusion 
of  the  bulb  of  the  urethra  simulating  cystocele  and  of  the  posterior  wall 
simulating  rectocele.  These  protruding  folds  attract  the  attention  of  the 
patient,  who  takes  them  for  a  "  falling  of  the  womb,"  and  they  annoy  and 
distress  her  by  becoming  eroded  through  leucorrhea  and  friction  ;  finally, 
if  there  be  a  true  cystocele  or  rectocele  besides,  the  i-edundancy  of  the 
vaginal  wall  increases  the  size  of  the  protrusion  and  the  di-agging  weight 
on  the  uterus. 

The  true  or  false  rectocele  or  cystocele  separates  the  labia  majora  when 
the  patient  is  erect ;  and  if  there  be  a  firm  cicatrix  at  the  site  of  the  rent, 
this  separation  is  constant,  whatever  the  patient's  posture.  The  vulvar 
cleft  and  vaginal  orifice  are  thus  made  to  gape,  and  the  vaginal  tube  is  more 
or  less  exposed  to  the  entrance  of  air  and  dust.  I  have  seen  even  slight 
partial  lacerations,  of  not  more  than  the  second  degree,  produce  this  effect 
when  the  cicatrix  happened  to  be  a  broad  one.  The  result  of  the  entrance 
of  air  and  dust  into  the  vagina  is  the  production  of.  a  profuse  irritating 
discharge  which  soon  excoriates  not  only  the  vagina  itself  but  also  the 
labia. 

Another  unpleasant,  if  not  serious  consequence  of  this  gaping  is  the 
entrance  and  retention  of  air  in  the  vagina,  while  the  patient  is  in  the  re- 
cumbent or  semi-prone  position,  or  when  she  happens  to  stoop  forwai'd, 
and  its  expulsion  with  an  audible  noise  when  the  erect  or  any  posture  i3 
assumed  in  which  intra-abdominal  pressure  again  asserts  itself.     This  phe- 


484 


GYlSrECOLOGICAL    OPEKATIONS. 


nomenon  has  been  designated  by  the  Germans  by  the  expressive  term 
"garrulifus  uu/u6t?,"  talkative  vulva,  and  may  cause  exceeding  annoyance 
to  the  woman  if  she  happens  to  be  in  company,  who,  of  course,  imagine 
the  flatus  to  be  from  its  usual  source,  the  rectum. 

As  a  result  of  the  cicatricial  covering  of  the  posterior  commissure  and 
the  gaping  of  the  vulva,  we  have  painful  (chiefly  in  the  minor  degrees  of 
partial  rupture,  when  the  penis  rubs  against  the  tender  scar)  or  unsatisfac- 
tory coition,  the  separated  labia  and  gaping  orifice  diminishing  the  friction 
necessary  to  perfect  intercourse.  In  the  one  case  the  sexual  act  is  dreaded 
by  the  wife,  in  the  other  it  is  not  enjoyed  by  the  husband,  and  the  conse- 
quence may  easily  be  marital  disagreements  and  infelicity.  As  the  out- 
come of  these  two  forms  of  dyspareunia,  and  more  still,  in  consequence  of 


Fig.  259.— Normal  Curve  of  Posterior  Vaginal  Wall 
(P.  F.  M.). 


Pig.  260.— Abnormal  Curve  of 
Posterior  Vaginal  Wall  after  Lac- 
eration of  Perineum  (P.  P.  M.). 


the  non-retention  of  the  semen  in  the  vagina  after  intercourse,  we  have 
sterility  in  a  certain  proportion  of  cases  of  lacerated  perineum.  The  exist- 
ence of  a  profuse,  acrid  leucorrhea,  which  kills  the  spermatozoa,  perhaps 
associated  with  a  cervical  catarrh,  aggravates  the  condition.  To  under- 
stand how  it  is  that  absence  of  the  perineum  may  produce  sterility,  one  has 
but  to  compare  the  relation  of  the  proper  curve  of  the  posterior  vaginal 
wall  and  perineum  to  the  external  os  (Fig.  259),  to  that  existing  when 
the  perineum  has  been  destroyed  (Fig.  260).  In  the  normal  condition 
the  cervix  dips  down  into  the  deepest  portion  of  the  vaginal  tract,  in 
which  by  law  of  gravitation  the  semen  naturally  accumulates  in  the  recum- 
bent position  after  withdrawal  of  the  penis.  The  external  os  is  thus 
bathed,  as  it  were,  in  the  semen,  and,  if  impregnation  does  not  take  place, 
it  IS  not  for  the  want  of  opportunity.     This  pouch  of  the  vagina  has  been 


SECONDAEY    OPERATION    FOR   LACERATED    PERINEUM.       485 

called  by  Sims,  who  first  advanced  this  theory,  the  receptaculum  seminis, 
and  the  pool  of  semen  in  it,  the  lac  seminis. 

Now  let  the  perineum  be  destroyed,  and  instead  of  the  normal  o 
curve,  the  posterior  vaginal  wall  curves  downward  toward  the  anus,  like  an 
S,  and  it  is  obvious  at  a  glance  that  the  receptaculum  seminis  is  absent, 
and  that  the  withdrawal  of  the  penis  must  be  at  once  followed  by  the 
gliding  out  of  the  semen  down  the  inclined  plane  of  the  S-  And,  indeed, 
this  is  what  patients  almost  invariably  report  when  they  consult  a  phy- 
sician for  acquired  sterility,  and  the  perineum  is  found  absent. 

While  theoretically,  and  in  many  instances  practically',  this  explanation 
is  sustained,  there  are,  doubtless,  more  cases  in  which  absence  of  the  peri- 
neum is  not  accompanied  by  sterility.  But  this  may  be  explained  by  the 
occurrence  of  ejaculation  directly  into  the,  in  such  cases  often,  gaping 
cervical  canal,  and  by  the  mysterious  fact  that,  no  matter  what  lesion  of 
the  genitals,  short  of  actual  atresia  or  absence  of  ovaries,  they  may  have, 
nothing  seems  to  prevent  a  certain  proportion  of  women  from  becoming 
pregnant. 

Thus  far  I  have  described  merely  the  results  of  partial  laceration.  In 
addition  to  the  evils  mentioned,  complete  rupture  has  peculiarly  distressing 
features  of  its  own,  the  chief  of  which  is  more  or  less  incontinence  of  the 
contents  of  the  rectum,  and  in  course  of  time  a  catarrhal  inflammation  of 
the  lower  portion  of  the  bowel  due  to  exposure. 

Absolute  incontinence  of  fecal  matter  and  fiatiis  occurs  only  when  the 
rent  extends  through  the  internal  sphincter.  If  the  fissure  is  only  through 
the  external  sphincter  ani,  solid  feces  can  almost  always  be  controlled,  and 
often  thin  evacuations  also,  if  the  rectal  mucous  membrane  is  not  inflamed 
or  irritable.  Flatus,  however,  is  usually  not  under  control  when  the 
external  sphincter  has  been  completely  severed.  Partial  fissures  of  the 
external  sphincter,  involving  only  the  outer  fibres  and  leaving  the  inner 
fibres  intact,  do  not  affect  the  faculty  of  retention.  In  complete  ruptures, 
retention  may  be  greatly  improved  by  cicatricial  contraction  of  the  lower 
extremity  of  the  rectum,  or  by  bands  stretching  across  the  fissure.  The 
presence  of  hemorrhoids,  external  and  internal,  generally  aggravates  the 
irritability  of  the  rectum. 

Many  patients  with  complete  rupture  are  perfectly  comfortable  and 
have  entire  control  unless  diarrhea  happens  to  set  in,  or  some  mental  ex- 
citement brings  on  an  unexpected  evacuation.  Then  they  are  liable  to  an 
involuntary  movement  at  any  time  or  place.  When  the  lacei-ation  extends 
above  the  internal  sphincter,  absolute  incontinence  is  the  rule,  and  such 
patients  are  among  the  most  deplorable  objects,  short  of  those  afllicted 
with  cancer,  which  it  is  our  fate  to  meet.  Even  a  woman  with  a  vesico- 
vaginal fistula  is  not  such  a  burden  to  herself  and  a  horror  to  others. 

Oftentimes  the  catarrh  of  the  rectum  extends  upward,  and  colitis,  with 
severe  colic  and  diarrhea,  intensifies  the  already  suflficiently  deplorable 
state  of  the  patient. 

Why  these  large  complete  ruptures  are  not  followed  in  proportion  by 
prolapsus  of  the  vagina  and  uterus,  I  have  already  explained. 


486  GYNECOLOGICAL    OPERATIOlSrS. 

Treatment. — I  have  already  made  the  statement  that,  if  the  practice 
were  universally  adopted,  as  it  should  be,  to  unite  all  lacerations  of  the 
perineum  of  greater  depth  than  the  first  degree  immediately  after  their 
occurrence,  the  cases  coming  under  the  care  of  gynecologists  for  the  sec- 
ondary operation  would  scarcely  be  one-fourth  of  the  number  now  met 
with.  It  is  true  that  a  certain  proportion,  perhaps  one-third,  of  these  pri- 
mai-y  operations  must  be  failures  (this  is  unquestionably  too  large  a  pro- 
portion for  private  practice,  although  in  hospitals  it  is  about  coiTect)  ;  and 
a^ain,  it  occasionally  happens  that  even  quite  a  deep  tear  unites  sponta- 
neously with  no  other  treatment  than  tying  together  the  knees  and  the 
lateral  position.  But,  while  union  after  the  primary  operation  is  the  rule, 
and  union  without  operation  the  exception,  there  are  still  a  fair  number  of 
practitioners  who  are  either  too  timid  to  admit  that  they  have  allowed  a 
perineum  to  tear  (an  accident  which  even  the  most  skilful  cannot  always 
prevent),  or  so  ignorant  and  careless  as  to  neglect  ascertaining  whether  it 
has  taken  place.  These  last  are  the  men  who  "have  never  had  a  lacerated 
perineum  in  a  practice  of  thirty  years  "  (sic  !).  Others  again,  I  am  happy  to 
sa}-  less  numerous,  are  so  wiKul  and  illogical  as  to  claim  that  the  immediate 
suture  of  a  perineal  laceration  is  injurious,  as  septic  elements  might  be 
included  in  the  wound  and  be  thus  removed  from  disinfection  {sic  f),  little 
thinking  how  much  greater  the  danger  of  infection  is  from  the  lochia  flow- 
ing over  the  open  perineal  wound. 

Tiiere  is  but  one  valid  exception  to  the  immediate  closure  of  a  large 
perineal  laceration,  and  that  is  when  the  rent  extends  so  far  into  the  rec- 
tum as  to  render  the  operation,  in  the  exhausted  condition  of  the  patient, 
too  hazardous.  In  such  a  case,  the  patient  may  be  given  twelve  to  fifteen 
hours  to  rally,  and  if  then  stiU  found  impracticable,  the  operation  had  better 
be  defen-ed  until  involution  has  taken  place.  To  postpone  all  immediate 
operations  for  twelve  or  twenty-four  hours,  as  has  been  proposed,  is  simply 
trifling  with  the  chances  of  union. 

As  I  have  often  noticed  the  interest  excited  in  my  audience  when  I 
took  occasion  to  describe  the  method  usually  employed  by  me  in  the 
primary  suture  of  this  lesion,  I  wiU  crave  indulgence  to  go  sUghtly  out  of 
my  way  and  briefly  describe  the 

Primary  Operation. — In  every  jorimiparous  labor,  as  soon  as  the  placenta 
is  expelled,  I  insert  the  index-finger  into  the  rectum,  and  the  thumb  into 
the  vagina,  and  between  the  two  estimate  accurately  whether  and  how 
deep  a  laceration  has  taken  place.  For  the  sake  of  verifying  the  result 
thus  obtained,  I  then  thoroughly  expose  and  cleanse  the  vulva,  and  by  a 
good  light  separate  the  labia  and  satisfy  myself  of  the  full  extent  of  the 
tear,  and  whether  the  sphincter  ani  or  the  posterior  vaginal  wall  is  in- 
volved or  not.  By  approximating  the  labia  I  also  estimate  the  length 
of  the  rent  with  the  parts  in  their  natural  relation,  for  it  must  be  re- 
membered that  the  swollen,  discolored  appearance  of  the  gaping  vulva  is 
liable  to  distort  reahty  and  to  magnify  a  tear.  Having  now  found  that  the 
rent  is  one  of  the  second  degTee,  at  least ;  that  it  is  not  superficial,  but  in- 
volves the  whole  substance  of  the  perineum  (as,  indeed,  such  rents  usually 


SECOT^DAEY    OPERATION    FOR    LACERATED    PERINEUM.       487 

do),  I  at  once  inform  the  patient's  friends  of  the  fact  (tlie  possibility  of 
which  I  am  always  careful  to  impress  upon  them  during  every  primiparous 
labor),  and  instructing  the  nurse  to  maintain  contraction  of  the  uterus  by 
gentle  friction,  I  proceed  to  prepare  my  instruments  in  an  adjoining  room. 
These  consist  of  a  stout,  flat  needle,  three  and  a  half  inches  lono-,  with 
bilateral  cutting  edges,  cmwed  so  that  from  point  to  head  the  distance 
is  but  two  and  a  half  inches  (Fig.  219) ;  a  small  needle-holder  which 
I  always  carry  in  my  pocket-case,  and  No.  2  braided  silk,  dipped  in  five 
per  cent,  cai'bolic  solution  when  used.  Having  threaded  the  needle  with 
suflS.cient  silk  to  last  for  all  the  stitches  probably  required,  I  proceed  to 
the  bedside,  and  quietly  inform  the  patient  that  she  is  slightly  torn  and 
will  require  a  stitch  or  two,  which  will  hurt  her  but  very  httle.  If  she 
grows  nervous  and  objects  greatly,  I  let  the  nurse  give  her  a  few  whiffs  of 
chloroform  on  a  handkerchief,  all  the  while  keeping  her  hand  on  and  rub- 
bing the  fundus  uteri,  the  patient  lying  on  her  back,  and  as  soon  as  prac- 
ticable I  turn  the  patient  crosswise  in  bed,  and  bring  her  hips  well  down 
to  the  edge,  with  her  feet  resting  on  the  bed  close  to  the  hips,  I  now 
compress  the  uterus  gently  but  firmly,  in  oi-der  to  expel  any  coagula  or 
fluid  blood  which  it  may  contain,  and  again  intrust  its  care  to  the  nurse. 
A  disinfected  sponge  of  about  the  size  of  an  apple  (not  larger,  as  it  is  diflS- 
cult  to  remove  later  on)  is  now  placed  in  the  vagina,  to  absorb  blood  and 
prevent  it  soiling  the  rent.  I  take  my  place  outside  of  the  left  thigh  of 
the  patient  and  (being  right-handed)  pass  the  index-finger  of  my  left  hand 
into  the  rectum.  The  right  thigh  is  supported  by  an  assistant,  whoever  it 
may  be,  and  I  manage  to  control  the  left  thigh  with  my  bod}'.  Or,  if  the 
assistant  is  sti*ong  enough,  he  or  she  can  hft  both  feet  with  flexed  knees 
and  thighs  into  the  gluteo- dorsal  position,  and  thus  give  me  uninterrupted 
approach  to  the  vulva.  With  my  left  index-finger  in  the  rectum  as  a  guide, 
I  insert  the  point  of  the  large  needle,  which  is  firmly  grasped  in  the  needle- 
holder,  about  one-fourth  of  an  inch  to  the  right  of  the  bottom  of  the  rent, 
and  with  a  quick  sweep  carry  it  completely  under  the  rent,  emerging  at  a 
corresponding  spot  on  the  left  side  ;  the  second  needle  is  passed  in  pre- 
cisely the  same  way,  and  so  on,  until  the  fourchette  is  reached,  where  the 
uppermost  suture  must  lie.  Particular  care  must  be  taken  to  have  the 
sutures  all  outside  and  under  any  rents  which  there  may  be  in  the  vaginal 
wall,  such  as  are  most  liable  to  happen  along  the  descending  rami  of  the 
pubic  arch,  and  not  to  allow  the  suture  to  escape  from  the  tissues  during 
any  part  of  its  course.  It  is  rare  that  a  partial  rent  of  the  third  degree 
requires  more  than  four  sutures.  Having  inserted  all  the  sutures,  the 
wound  is  thoroughly  cleansed,  and,  beginning  with  the  first,  the  stitches 
are  tied  with  the  knot  slightly  to  the  side  of  the  rent,  until  the  uppermost 
is  reached,  when  the  sponge  is  removed,  and  the  last  stitch  rapidly  tied. 
The  sutures  are  cvit  off  about  one-fourth  of  an  inch  from  the  knot.  If  the 
vagina  should  happen  to  be  torn  some  distance  up,  it  would  be  well  to  sew 
this  rent  with  a  finer  needle  and  fine  catgut  (running  suture),  down  to  the 
perineum,  and  then  unite  the  latter  as  described.  I  have,  fortunately,  had 
but  one  opportunity  to  sew  a  complete  rupture  immediately  after  its  occur- 


488  GYNAECOLOGICAL    OPERATIONS. 

rence,  and  in  that  case  I  proceeded  precisely  as  I  have  related,  it  being  a 
sli"-ht  case,  including  the  edges  of  the  torn  sphincter  in  my  first  stitch,  and 
obtaining  union  by  first  intention.  In  another  case  of  complete  nipture  of 
the  second  degree,  which  I  saw  in  consultation  forty  hours  after  its  occur- 
rence, I  gave  but  Uttle  hope  of  iinion  at  that  late  hour,  but  operated,  at  the 
request  of  the  friends,  with  sUver  sutures  introduced  as  to  be  described  for 
the  secondary  opei'ation  ;  owing  to  hyj^er-catharsis  union  was  not  obtained. 

In  complete  laceration  involving  the  septum,  I  should  first  unite  the 
rent  in  the  latter  separately,  knotting  the  stitches  in  the  rectum  and  cut- 
ting them  short,  and  then  proceed  as  in  partial  laceration.  The  rectal 
stitches  can  be  allowed  to  cut  out,  or  catgut  may  be  used. 

The  stitches  after  primaiy  operations  are  removed  on  the  fourth  or  fifth 
day,  the  ordinary  daily  vaginal  douches  having  been  given  and  the  bowels 
moved  by  compound  licorice  powder  or  Hunyadi  v^ater  aided  by  enema 
on  the  third  day,  in  the  hands  of  a  competent  nurse.  In  complete  lacera- 
tions this  first  movement  of  the  bowels  requires  the  most  careful  attention, 
and  the  physician  would  do  well  to  be  present  and  administer  the  enema 
himself.     ]More  detailed  rules  for  this  manipulation  will  be  given  later  on. 

Of  late,  Dr.  Alloway,  of  Montreal,  has  advocated  closing  fresh  lacerations 
by  one  wire  suture  passed  as  near  as  possible  all  around  the  upper  margin 
of  the  rent,  and  twisted  on  the  skin.  He  claims  that  this  single  suture 
closes  the  whole  tear,  and  that  entire  primary  iinion  is  the  rule.  His  ex- 
perience is  corroborated  by  Dr.  Lee,  of  Cleveland,  Ohio,  and  the  plan 
seemed  so  plausiljle,  while  it  spares  the  patient  the  suffering  of  more  stitches, 
that  I  have  employed  it  in  two  cases  of  moderate  partial  rupture  with  per- 
fect success.  Dr.  B.  F.  Dawson,  of  New  York,  informs  me  that  he  has  lately 
adopted  the  same  principle  successfully  in  the  secondary  oj)eration.  If 
found  generally  efficient,  this  single  suture  would  certainly  be  a  great  im- 
provement. 

If  the  primary  operation  has  been  neglected  or  has  failed,  no  other 
course  remains  but  to  wait  until  complete  involution  has  been  accom- 
plished, and  then,  if  the  sjinptoms  demand  it  or  delay  is  hkely  to  be  pro- 
ductive of  evil  results  such  as  I  have  described,  to  perform  the  secondary 
operation. 

The  Indications  fok  the  Secondaey  Operation  must  be  sufficiently  appar- 
ent from  what  I  have  said  of  the  symptoms  and  evil  results  of  the  injury. 
As  to  the  advisability  of  restoring  every  perineum  torn  to  or  through  the 
sphincter  ani,  there  can  be  but  httle  dispute,  none  at  all,  indeed,  when  the 
rupture  is  complete. 

"^Tiether  minor  partial  lacerations  should  be  repaired  depends  mainly 
on.  the  severity  of  the  symptoms  produced  by  them  (dyspareunia,  sterility, 
rectocele,  or  cystocele),  and  partly  on  the  desii-e  of  the  woman  to  be  as 
nearly  perfect  as  possible  in  her  genital  organs,  as  in  other  respects.  It  is 
as  easy  to  exaggerate  the  indications  for  perineorrhaphy  as  for  trachelor- 
rhaphy, although  there  can  be  no  question  as  to  the  propriety  of  closing  a 
well-marked  perineal  laceration. 

In  a  case  of  so-called  "sundering"  or  paralysis  of  the  perineal  mus- 


BRIEF    HISTORY    OF    SECOJ^DARY    PERIIS-EORRHAPIIY.         489 

cles,  the  question  must  be  weiglied  as  to  whether  it  is  worth  the  risk  to 
spHt  the  perineum  and  endeavor  to  restore  its  tone  by  narrowing  the  va- 
ginal orifice.  As  a  rule,  I  should  hesitate  to  do  this,  since  there  is  usually 
in  such  cases  so  Uttle  elasticity  left  in  the  tissues  as  to  preclude  the  possi- 
bility of  their  ever  regaining  their  tone.  I  should  prefer  to  naiTow,  and 
have  done  so  successfully,  the  whole  posterior  wall  of  the  vagina,  as  will 
be  described  for  prolapsus,  or  by  pex-forming  Emmet's  new  operation  de- 
scribed on  page  505. 

Object  of  the  Secondary  Operation. — In  performing  a  plastic  operation 
on  an  old  perineal  rent,  the  object  is  not  only  to  restore  the  perineum  itself 
to  its  original  integrity  as  nearly  as  possible,  and  to  give  to  it  again  its 
function  as  the  support  of  the  vagina,  and  through  it  of  the  neighboring 
organs,  but  also  so  to  influence  the  vagina  itself  as  to  overcome  whatever 
dislocations  of  that  canal  may  have  gradually  developed,  such  as  rectocele, 
cystocele,  and  in  a  secondary  line,  descensus  of  the  utei'us.  Accordingly 
as  the  operation  is  confined  to  the  perineum,  or  is  extended  to  the  poste- 
rior vaginal  w^all,  it  is  called  simple  perineoiThaphy,  or  colpo-perineor- 
rhaphy.  The  operation  for  cystocele,  or  anterior  coliDorrhaphy,  does  not 
properly  belong  to  this  chapter  at  all,  but  will  be  considered  separately. 

Perineorrhaphy,  then,  aims  to  bring  together  the  long-separated 
halves  of  the  torn  perineum  ;  colporrhaphy,  to  naiTow  in  a  longitudinal 
direction  the  vaginal  canal,  whether  this  be  on  the  posterior  or  the 
anterior  wall.  A  firm  posterior  cicatrix  extending  from  the  perineum  to, 
or  nearly  to,  the  cervix,  and  supported  by  a  solid  muscular  perineum  below, 
will  evidently  accomplish  the  object  of  preventing  a  return  of  the  vaginal 
prolapse.  Whether  it  does  so  permanently  for  the  uterus  remains  to  be 
seen. 

Brief  History  of  Secondary  Perineorrhaphy. 

Although  many  operators  from  the  time  of  Ambroise  Pare  attempted 
this  ojoeration,  but  few  succeeded  in  obtaining  even  partial  results,  until 
Roux,  in  1832,  by  means  of  the  now  abandoned  quill-suture,  cured  four 
out  of  the  five  cases  on  which  he  operated.  Dieftenbach  and  Laugenbeck, 
in  Germany,  were  also  fairly  successful.  Since  then,  with  some  inter- 
missions, the  ojoeration  has  gTadually  been  improved  upon,  that  is,  simpli- 
fied, chiefly  by  Simon  in  Germany  (who  used  siUc  exclusively),  Baker 
Brown  in  England,  and  Sims  and  Emmet  in  America,  until  now  it  has  be- 
come one  of  the  ordinary  and  most  successful  operations  in  gynecological 
surgery.  The  pecuharity  of  the  operation  is  that  nearly  every  operator  of 
repute  has  felt  stimvilated  by  it  to  devise  some  special  modification  which 
is  thenceforth  known  as  his  operation,  and  as  a  result  the  number  of 
methods  for  operating  on  old  perineal  lacerations,  chiefly  when  combined 
with  prolapsus  of  the  uterus  and  vagina,  has  increased  so  gi'eatly  within 
the  last  few  years  that  it  is  absolutely  impossible  to  remember  them  all, 
let  alone  spare  the  space  to  describe  them.  Doubtless  each  has  its  ad- 
vantages, or  it  would  not  have  been  devised.  But  I  have  found  from  my 
own  experience  that,  when  the  case  presents  comphcations,  each  operator 


490  GYNECOLOGICAL    OPERATION-S. 

does  best  to  adopt  for  liiinself  the  method  to  suit  his  particular  case.  And 
comparing  these  various  methods,  I  have  arrived  at  certain  conclusions  as 
to  which  plan  of  operation  is  usually  the  most  successful  in  a  certain  foi-m 
of  lesion  ;  and  these  I  shall  describe  in  these  pages,  making  the  details  as 
clear  and  as  simple  as  possible,  and  referring  briefly  here  and  there  to 
other  methods  which  may  seem  useful  at  times. 

The  methods  of  operation,  then,  which  I  shall  describe  will  be  those 
which  I  have  found  most  successful  in  my  own  practice.  Essentially  they 
are  those  of  Emmet  and  Thomas,  combined  with  those  of  Simon  and 
Hegar. 

Preparatory  Treatment  for  Perineorrhaphy. 

It  is  the  exception  to  find  an  old  laceration  of  the  perineum  in  need  of 
preparatory  treatment  for  operation.  The  rent  has  cicatrized  over,  and 
such  redundant  tissue  as  there  may  be,  either  about  the  anus  (hemorrhoids, 
folds  of  skin)  or  in  the  vagina,  is  removed  most  easily  and  rapidly  at  the 
operation.  Only  in  case  there  is  considerable  j)rolapsus  of  the  vagina  and 
uterus,  may  it  be  adrisable  to  retain  these  jDarts  in  position  by  astringent 
tampons  or  a  pessary,  if  there  is  time  for  such  palhative  measures. 

The  attention  to  be  paid  to  the  estabhshment  of  the  general  health  be- 
fore operating  has  ah-eady  been  refeiTed  to.  One  point  of  special  imjDort- 
auce,  particulaxiy  in  complete  lacerations,  is  the  care  of  the  bowels,  which 
for  at  least  a  week  before  the  operation  should  be  regulated  by  mild  laxa- 
tives (compound  hcorice  powder,  compound  rhubarb  pills,  or  equal  parts  of 
sulphur,  magnesia,  and  cream  of  tartar),  so  as  to  have  two  full  evacuations 
daily.  I  have  been  sm-prised  to  see  the  amount  of  fecal  matter  evacuated 
from  bowels  which  were  supposed  to  be  regularly  moved  every  day,  and  it  is 
exceedingly  annoying  as  w^ell  as  detrimental  to  the  success  of  the  operation  to 
find  the  rectum  filled  by  soft  pultaceous  fecal  matter  several  days  after  the 
operation,  when  the  upper  intestine  was  supposed  to  have  been  thoroughly 
unloaded  immediately  beforehand.  Only  by  mild  preparatory  catharsis 
for  one  or  two  weeks  can  a  thorough  clearing  out  be  achieved.  The  last 
evacuation  by  laxatives  should  take  place  on  the  day  before  the  operation, 
or  at  the  latest  in  the  morning  if  the  operation  is  to  be  done  in  the  after- 
noon. An  hour  before  the  operation  a  full  enema  of  soapsuds  should  be 
given  to  make  sure  that  the  rectum  is  well  emptied. 

Hyper-catharsis  is  almost  as  bad  as  the  reverse,  for  it  is  anything  but 
pleasant  to  see  (and  smell)  a  gush  of  Hquid  feces  spurting  or  oozing  from 
the  anus  under  the  expulsive  efforts  of  ether-retching  during  the  operation, 
not  to  mention  the  danger  of  contaminating  the  wound.  In  case  this  oc- 
cur.s,  a  plug  of  cotton  or  a  sponge  may  be  inserted  into  the  rectum  as  a 
protective  ;  but  I  once  saw  plug  and  feces  together  forced  out,  narrowly 
missing  my  face. 

Light  but  nutritious  diet  should  be  given  for  a  week  prior  to  the  opera- 
tion, and  milk  is  to  be  avoided,  as  it  leaves  caseous  excreta.  Immediately 
before  the  operation,  a  hot  carbolized  vaginal  douche  is  given. 


PKEPARATOEY    TREATMENT   FOR    PERINEORRHAPHY. 


491 


Instruments. — We  in  this  country  gi-eatly  prefer  scissors  to  knives  in 
denuding-  a  perineum  ;  the  denudation  can  be  made  more  rapidly  and  su- 
perficially, since  it  is  not  necessary  to  remove  pieces  of  fascia  and  muscle 
but  only  the  mucous  membrane  and  cicatricial  tissue  in  order  to  get  a  raw 
surface  for  primary  union,  and  the  wound  heals  quite  as  readily  as  that  of 
a  knife.  The  advantage  claimed  for  the  scissors,  of  causing  less  hemor- 
rhage because  the  tissues  are  more  or  less  bruised,  is,  I  think,  a  fancied  one. 
Sharp  scissors  bruise  but  little,  if  any.  The  scissors  usually  employed  are 
slender,  bent  at  an  obtuse  angle  to  the  shaft,  right  and  left,  slightly  curved 


Fig.  261. — Emmet's  Perineum  Sci.osors. 

on  the  flat,  with  moderately  sharp  points  (Fig.  261).  The  tissues  to  be  re- 
moved are  grasped  and  lifted  uj),  seriatim,  by  a  tissue  forceps  of  Thomas' 
invention  (Fig.  262  ),  or  by  a  tenaculum,  preferably  the  forceps.  The 
needles  are  straight,  round  darning-needles,  two  inches  and  one  and  one- 
half  inch  long.  Needle-holder,  shield,  twister,  etc.,  are  the  same  as  in 
cervix  operations.  Wire  No.  26  or  27,  and  No.  33  for  sujDCi-ficial  sutures. 
At  least  six  needles,  four  long  and  two  short,  and  ten  wire  sutures,  10  to 
12  inches  long  each,  should  be  prepared  for  each  operation. 

Assistants. — Four  assistants  and  a  nurse  are  required  ;  one  to  give  the 
anesthetic,  two  to  hold  each  a  knee  and  sponge,  and  the  fourth  to  hand  in- 
struments, attach  wire,  thread  needles,  etc.    The  nui'se  washes  the  sponges. 

The  apparatus  recently  imported  from  abroad,  by  which  the  knees  and 
hands  are  joined  immovably,  and  the  patient  is  kept  in  the  gluteo-dorsal 
position  without  the  two  assistants  for  the  legs,  is  very  useful  for  lithotomy, 
no  doubt.  But  for  perineorrhaphy  it  does  not  answef  so  well,  because  the 
duty  of  these  two  assistants  is  not  only  to  hold  the  legs  of  the  patient,  but 


Fig.  2G2. — Thomas'  Tissue  Forceps. 

also  to  separate  equally  the  labia  during  every  stej)  of  the  operation,  espe- 
cially when  the  operator  reaches  the  angle  inside  of  the  rami  of  the  pubes. 
If  this  is  not  done,  and  weU  done,  the  denudation  will  either  be  imperfect 
or  asymmetrical. 

Position  of  Patient  and  Operator. — The  gluteo-dorsal,  with  external 
genitals  at  the  very  edge  of  the  table,  the  knees  beut  on  the  abdomen  and 
supported  by  the  corresijonding  arms  of  the  assistants,  who,  if  they  be- 
come tired,  may  pass  the  patient's  legs  over  their  necks  and  support  them 
in  that  position. 


492 


GYNECOLOGICAL    OPERATIONS. 


Tlie  patient  must  lie  perfectly  flat  on  her  back,  so  as  to  have  both 
sides  of  the  vulvar  cleft  on  an  even  level.  The  best  of  light  is,  of  course, 
imperative. 

The  operator  sits  immediately  in  front  of  the  patient,  directly  in  the 

median  line. 


The  Opebation  of  Secondary  Peeineoerhaphy. 

For  Incomplete  Laceration. — The  patient  having  been  placed  carefully 
in  position  the  operator  traces  the  outline  of  the  cicatrix  indicating  the 
original  perineal  wound,  and  by  approximating  the  labia  ascertains  how 
much  surface  he  must  remove  in  order  to  insure  thorough  coaptation. 

The  novice  must  remember  that  it  is  not  only  the  cutaneous  surface  of 
the  perineum  which  he  wishes  to  restore,  but  the  whole  triangular  mass, 
known  as  the  "perineal  body"  (see  Thomas'  "Diseasesof  Women,"  pp.  155 
to  168) ;  and  that  the  denudation  must  accomplish  that  object.     It  must 


.rr^~ 


Fig.  263.— Cicatrix  of  Lacerated  Peri- 
neum.    Third  degree  (P.  F.  M.). 


Fig.  264.— Shape  of  Denudation  for  Lac- 
eration in  Fig.  2Ho  (P.  F.  M.). 


therefore  extend  upward  along  the  posterior  vaginal  wall,  outward  on  each 
labium,  and  backward  toward  the  anus,  as  far  as  the  cicatrix  shows  the 
original  perineum  to  have  been  torn.  Fig.  263  shows  the  usual  appear- 
ance of  the  cicatrix  of  a  partial  laceration  of  the  third  degree.  Just  so  large, 
and  to  make  union  more  certain,  a  little  larger  in  every  direction,  must  be 
the  denudation. 

From  the  accompanying  diagrams  the  shape  and  limit  of  the  area  of 
denudation  will  be  ai:)parent.  It  resembles  the  body  with  wings  extended 
of  a  bat  or  butterfly,  the  two  lateral  triangular  spaces  being  the  wings  and, 
meeting  in  the  centre,  the  body.  If  the  rent  is  a  conjparatively  superficial 
one  and  does  not  extend  up  into  the  vagina,  or  there  is  no  rectocele,  the 


OPERATION    OF    SECONDARY    PERINEORRHAPHY. 


493 


denuded  area  has  tlie  shape  of  Fig.  267.  But  if  there  is  a  rectocele,  the 
body  of  the  bat  projects  upward  as  in  Fig.  2G8.  The  difficulty  with 
students  generally  is  (it  certainly  was  with 
me)  to  understand  why  the  upper  border  of 
the  denudation  should  be  concave  on  either 
side  of  the  median  line,  and  project  in  the 
centre.  The  explanation  lies  in  the  fact  that 
the  vagina  is  a  tube,  and  that  while  the  de- 
nudation on  the  labia  a  a  is  on  the  same 
level  as  the  limit  of  the  denudation  on  the 
posterior  vaginal  wall  b  b,  the  natural  curve 
of  the  vaginal  tube  brings  the  point  c  c  at  a 
lower  level.  If  the  vagina  were  a  flat  sur- 
face, the  points  a,  c,  b,  and  b,  c,  a  would  be 
on  the  same  plane.  The  higher  up  on  the 
posterior  vaginal  wall  the  vivification  goes, 
the  deeper  the  grooves  c  c. 

The  object  of  the  operator  must  be  to  so  denude  the  lateral  halves  of 
the  perineum  and  the  posterior  vaginal  wall  as  to  bring  a  and  a  in  Fig.  267 
and  a  and  a,  and  b  and  b,  and  d  and  d  in  Fig.  268  in  accurate  apposition 


a 

Fig.  265.— Section  View  of  Perineum. 
a  a,  rectal  surface  ;  a  6,  perineal  turface ; 
b  V,  vaginal  surface  (P.  F.  M.). 


Fig.  267.— Shape  of  Area  of  Denudation  for  Partial  Laoera- 
ation.  Second  degree,  b,  c.  show  the  median  line ;  a  a,  the  points 
on  the  labia  to  be  united  (P.  F.  M.). 


Fig.  266.— tr,  One-half  of 
Area  of  Denudation  without 
Rectocele.  6,  one-half  of  area  of 
denudation  when  the  lacera- 
tion is  a  deep  one,  with  recto- 
cele ;  V,  vagina  ;  p,  perineum  ;  I, 
labium  (P.  F.  M.). 


Fig.  268.— Shape  of  Area  of  Denudation  for  Laceration  of 
Perineum  with  Moderate  llectocele.  a,  a,  labia  niajora ;  h,  b, 
rectocele,  or  posterior  vaginal  wall ;  c,  r,  lateral  vaginal  furrow  ; 
d,  d,  perineum  (P.  F.M.). 


when  the  sutures  are  twisted.  The  median  line  b,  c  then  constitutes  the 
raphe  of  the  new  perineum,  precisely  where  that  of  the  original  perineum 
existed,  and  the  points  a,  b,  a  united  are  the  posterior  commissure. 


494  GYNECOLOGICAL    OPERATIONS. 

In  beoinning  the  operation  tlie  novice  may  do  well  to  trace  out  the 
limit  of  the  space  to  be  denuded  by  trimming  off  a  narrow  strip  of  mucous 
membrane  from  the  inner  side  of  the  left  labium  majus  at  I  (Fig.  266,  a)  to 
the  bottom  of  the  rent  at  p,  and  then  up  the  middle  of  the  posterior 
vaginal  wall  to  v,  and  back  to  l.  In  this  way  a  triangular-shaped  space 
will  be  included  in  three  bleeding  furrows,  and  the  enclosed  mucous  mem- 
brane can  then  be  trimmed  off,  and  the  same  is  subsequently  done  on  the 
other  side,  and  the  two  bleeding  triangles  are  joined  to  make  the  woimd 
represented  in  Fig.  267.  Thomas  illustrates  this  step  very  neatly  by  cut- 
ting two  triangles  like  Fig.  266,  a  out  of  paper,  and  joining  them  in  the 
centre  by  pasting  linen  on  both  sides.  The  open  flaps  will  then  represent 
the  area  of  denudation,  and  when  approximated  they  illustrate  the  union  of 
the  perineal  flaps  by  sutures.  Even  the  expert  wiU  do  well  to  mark  the 
spot  on  the  posterior  vaginal  wall  which  shall  be  the  limit  in  that  direction 
of  the  denudation,  a  spot  which  he  determines  by  lifting  up  Avith  a  tenacu- 
lum the  highest  point  of  the  mucous  membrane  there  which  he  can  carry 
without  force  to  a  level  with  the  upper  limit  of  the  original  perineum  on 
the  labium  majus  (about  half-way  between  anus  and  meatus  urinarius) 
and  snipping  out  a  little  speck,  which  he  can  recognize  when  denuding. 
This  guide  will  prevent  too  high  a  denudation. 

A  study  of  the  foregoing  description  and  comparing  it  with  the  dia- 
grams, must,  it  seems  to  me,  render  the  comprehension  of  this  operation 
an  easy  matter.  I  will  now  proceed  to  describe  the  technical  details.  Hav- 
ing traced  out  in  mind  or  by  a  bloody  furrow  the  limits  of  the  area  of 
denudation,  as  marked  by  the  border  of  the  cicatrix  and  the  slight  wound 
made  on  the  posterior  vaginal  wall  as  just  described,  the  operator  with  the 
tissue  forceps  seizes  a  superficial  fold  of  mucous  membrane  on  the  inside 
of  the  left  labium  majus  at  the  point  (Fig.  264,  a)  which  he  has  chosen  for 
the  futiu'e  posterior  commissure  (usually  about  midway  between  meatus 
and  anus),  and  with  the  left-bent  scissors  trims  off  a  strip  of  tissue  which 
is  partly  skin  and  partly  mucous  membrane  down  to  the  bottom  of  the 
rent  (c)  nearest  the  anus,  and  up  on  the  right  labium  until  he  reaches  a  spot 
(a)  con-esponding  to  a,  when  he  cuts  off  the  ribbon-like  flap,  which  he  has 
trimmed  off.  He  may  now,  if  he  is  ambidexter,  take  the  right-bent  scis- 
sors and  retrace  his  steps  to  the  left  side,  then  back  to  the  right,  and  so  on, 
hfting  up  the  beginnings  of  each  ribbon  with  the  tissue  forceps  or  tenacu- 
lum, and  endeavoring  not  to  break  the  strip  from  side  to  side,  until  the 
upper  hrnit  of  the  denudation  is  reached.  The  novice  will  fear  that  he 
may  cut  through  the  septum  into  the  rectum  ("buttonhole"  it),  and  so 
he  might  if  he  cuts  too  deeply,  picks  up  too  much  tissue  in  the  forceps,  or 
uses  a  scissors  too  sharply  curved  on  the  flat.  But  if  he  is  careful  always 
to  keep  Emmet's  flat  scissors  level  with  the  surface  so  that  only  the  mucous 
membrane  can  be  trimmed  off,  and  if  he  always  sees  just  what  and  how 
much  tissue  the  blades  enclose  before  he  cuts,  he  will  not  do  any  damage. 
Large  veins,  which  are  numerous  in  the  recto-vaginal  septum,  can  be  seen 
and  avoided,  especially  if  the  ribbon  be  always  held  taut  with  the  forceps. 
If  the  ribbon  breaks  at  any  spot,  the  tissue  forceps  must  take  a  fresh  bite. 


OPERATION    OF    SECONDARY    PERINEORRHAPHY. 


495 


and  the  paring  goes  on.  The  width  of  the  strip  of  skin  or  mucous  mem- 
brane which  can  easily  be  peeled  off  at  each  trip  from  side  to  side  is  about 
one-fourth  of  an  inch.  It  is  evident  thus  that  a  rapid  and  skilful  opera- 
tor can  denude  a  space  often  measuring  four  inches  from  a  to  a,  and  three 
inches  from  b  to  c,  in  a  comparatively  short  space  of  time,  say  twenty  min- 
utes to  half  an  hour. 

If  an  arterial  branch  or  a  vein  is  cut,  which  occasionally  happens,  it  is 
simply  seized  with  artery  forceps,  which  are  allowed  to  hang  until  the 
denudation  is  finished  ;  the  ar- 
tery is  then  twisted,  the  vein 
will  probably  have  ceased  to 
bleed  without  this,  and  any  re- 
maining hemorrhage  promptly 
stops  when  the  sutures  are 
twisted. 

While  the  denudation  is 
under  progress,  the  index  and 
middle  finger  of  the  left  hand  of 
the  assistant  who  holds  the  left 
leg,  and  the  right  hand  of  the 
other  assistant  separate  the  labia 
by  traction  on  the  sound  skin, 
and  enable  the  operator  to  see 
the  vaginal  canal  as  he  proceeds 
inward.  This  traction  must  be 
uniform,  and  is  regulated  by  the 
operator  at  will  during  the  whole  operation,  so  as  to  secure  the  best  pos- 
sible symmetry  of  the  two  halves  of  the  wound,  and  exactly  con-esponding 
points  of  entrance  and  exit  of  the  sutures. 

The  raw  surface  is  kejDt  well  sponged  by  the  assistant  holding  the  left 
leg,  or  by  both  assistants,  the  sponges  being  attached  to  holders  as  in  the 
cervix  operation.  If  any  small  islands  of  mucous  membrane  have  acci- 
dentally been  left  in  the  raw  surface,  they  should  be  trimmed  off,  and  the 
edges  of  the  wound  smoothed  as  neatly  as  possible,  before  introducing  the 
sutures.  Particular  care  should  be  taken  not  to  have  the  denudation  on 
the  labia  extend  too  high  up,  or  the  vaginal  orifice  may  be  made  too  small ; 
and  to  see  that  the  points  a,  a  correspond  exactly  in  shape  and  size,  or  else 
they  cannot  be  well  coaptated  by  the  sutures,  and  a  gaping,  raAV  fissure 
remains  at  the  posterior  commissure. 

When  the  denudation  has  been  completed,  the  wound  is  covered  with 
a  large  sponge  or  wet  cloth  for  a  few  moments  to  arrest  oozing,  the  oper- 
ator wipes  his  hands  on  a  wet  towel,  and  then  proceeds  to  introduce  the 
sutures,  handed  him  by  the  assistant  in  charge  of  the  instruments.  The 
index  and  middle  fingers  of  the  left  hand  are  passed  into  the  rectum,  the 
recto-vaginal  septum  is  lifted  up  and  put  on  the  stretch,  and  under  guid- 
ance of  the  fingers  in  the  rectum,  the  sutures  are  introduced  as  shown  in 
Fig.  269,  about  one-thii'd  of  an  inch  fi-om  the  edge  of  the  wound.     The 


Fig.  269. — Courso  of  Sutures  in  Secondary  Perineor- 
rhaphy (P.  F.  M.). 


496 


GYNECOLOGICAL    OPERATIONS. 


first  and  second  sutures  are  generally  passed  straight  through  underneath 
the  denuded  surface  without  emerging,  but  with  the  remainder  the  space 
is  too  wide,  and  it  will  generally  be  found  best  to  bring  the  needle  out  in 
the  middle  of  the  wound  and  to  introduce  it  again  at  precisely  the  same 
spot,  so  as  to  have  none  of  the  sutui-e  exposed  on  the  raw  surface.     Only 


Fig.  270.— Section  View  of  Course  of  Sutures  in  Secondary  Perineorrhaphy,  and  Emmet's  Method  of 

securing  the  Ends. 

the  thread  should  be  drawn  out  of  this  central  aperture,  for  if  the  wire  also 
is  drawn  through  it  is  very  liable  to  kink  when  the  needle  is  reinserted  at 
the  same  spot.  To  avoid  drawing  out  the  wire  in  the  centre  the  assistant 
holding  the  left  leg  should  seize  and  hold  the  wire  back  with  his  left  hand, 
until  the  operator  has  reinserted  the  needle  and  brought  it  out  again  on 
the  right  side  of  the  wound.  In  doing  this,  and  to  enable  him  to  bring 
the  needle  out  at  a  sjDot  exactly  corresponding  to  the  point  of  entrance,  the 
free  thumb  of  the  left  hand  may  be  used  to  push  the  right  labium  down  on 
the  point  of  the  needle.  With  the  longer  sutures  care  should  be  taken  not 
to  force  the  needle  too  sharply  around  the  left  and  right  curves  of  the 
wound  in  jDassing  it  toward  the  centre  and  out  on  the  right  side  ;  most 
needles  are  broken  at  these  two  points,  particularly  if  finely  tempered,  as 
•most  of  these  straight  needles  are. 

The  needle   having   been   withdrawn   by   seizing   its   point  (not   too 
sharply)  with  the  needle-holder,  and  the  operator  and  assistants  watching 

the  wire  to  see  that  its  looj)  is  properly 
fastened  and  that  there  is  no  kink  to  pre- 
vent its  smooth  passage  through  the  long 
track  made  for  it,  the  operator  draws  the 
suture  through  with  the  needle-holder,  or 
for  fear  of  its  catching  grasps  it  with  both 
hands,  and,  with  a  rapid  back  and  forth  mo- 
tion to  fi-ee  it  from  any  obstruction,  draws 
it  through,  and  loosely  twists  the  ends  of 
the  wire  together.  Although  the  rectum 
should  be  perfectly  empty  and  clean,  the 
left  hand  must  be  wiped  on  a  wet  towel  before  grasping  the  suture  with 
it ;  if  there  happens  to  be  fecal  matter  in  the  rectum  care  must  be  observed 
not  to  contaminate  the  wound  or  the  needle  and  silk  with  the  left  hand, 
and  hence  I  prefer  to  draw  the  sutures  through  with  the  right  hand,  only 
using  both  when  there  seems  danger  of  the  wire  catching  in  its  track.'  The 


Fig.  271. 


-Hanks'  ITethod  of  securing 
Ends  of  Sutures. 


OPERATION"    OF    SECONDARY    PERINEORRHAPHY.  497 

twisted  ends  of  the  sutures  are  grasped  in  the  palm  of  the  left  hand  and 
thus  kept  out  of  the  way  while  introducing  the  remaining  stitches.  Spe- 
cial care  must  be  taken  not  to  allow  the  sutui'es  to  emerge  in  the  wound 
in  the  lateral  grooves,  hence  with  the  upper  sutures  the  straight  needle 
should  be  passed  first  directly  upward  in  the  dii-ection  of  the  pelvic  cavity, 
and  then,  the  groove  being  lifted  up  and  effaced  as  much  as  possible  by 
the  fingers  in  the  rectum,  carried  toward  the  centre  ;  the  same  precaution 
is  to  be  observed  on  the  right  side.  The  last  suture  should  pass  close  to 
the  edge  of  the  mucous  membrane,  and  be  brought  out  in  the  centre,  just 
tvilhin  the  toidenuded  surface,  so  as  to  include  this  point  in 'the  suture  and 
insure  the  exact  coaptation  of  the  raw  edges  at  the  new  posterior  commis- 
sure. 

The  interval  between  the  sutures  should  be  at  most  one-fourth  of  an 
inch ;  thus  a  laceration  of  the  second  degree  would  require  five  or  six,  one 
of  the  third  degree  six  to  ten  sutures,  in  pi*oportion  to  the  length  of  the 
perineum.  The  higher  up  on  the  posterior  wall  the  denudation  goes,  that 
is,  the  longer  the  projecting  tongue  seen  in  Fig.  268,  the  more  sutures  are 
reqi.iired. 

All  the  stitches  having  been  introduced,  the  wound  and  vagina  are 
thoroughly  cleansed,  the  operator  washes  and  disinfects  his  hands,  and  the 
twisted  ends  of  the  sutures  are  handed  to  an  assistant  to  hold  against  the 
mons  veneris.  The  operator  disentangles  suture  No.  1  nearest  the  rec- 
tum, draws  the  lips  of  the  wound  together,  bends  the  wires  at  right  angles 
to  the  skin  close  to  the  wound,  and,  gi'asping  an  end  in  each  hand,  with  a 
quick  sweep  crosses  his  arms  several  times  and  thus  gives  the  wire  a  few 
twists,  sufficient  to  hold  the  parts  together  temporarily.  This  is  done 
with  each  successive  suture,  the  w'ound,  being  carefully  dried  just  before 
twisting,  and  the  skin  being  brought  in  smooth  apposition.  When  all  the 
sutures  are  thus  temporarily  twisted,  the  wire-twister  and  shield  are  used 
to  secure  them  permanently,  each  twisted  suture  being  left  about  thi'ee 
inches  long ;  and  the  ends  of  all  together  are  then  joined  in  a  small  piece 
of  rubber  tubing  about  one-fourth  of  an  inch  long,  on  the  outside  of 
which  the  free  ends  of  wire  are  bent  down  and  again  secui-ed  by  tightly 
winding  a  bit  of  wire  around  them  and  the  tubing.  (See  Fig.  270.)  Or 
the  wires  may  be  bent  as  shown  in  Fig.  271.  The  object  of  this  tubing  is 
to  keep  the  wires  together  and  prevent  their  scratching  the  patient's  thighs, 
and  to  facilitate  the  removal  of  the  stitches.  If  necessary,  superficial  sut- 
ures are  now  introduced,  either  of  fine  Avire  or  silk. 

The  vagina  is  now  wiped  dry  with  a  sponge  on  holder,  the  perineum 
cleaned,  dusted  with  iodoform  (if  thought  advisable,  or  if  in  a  hospital), 
and  the  operation  is  completed. 

After-treatment.— The  patient's  thighs  just  above  the  knee  are  loosely 
bandaged  together,  and  she  is  allowed,  indeed  encouraged,  to  lie  on  her 
side  as  much  as  she  chooses.  The  new  perineum  is  not  to  be  touched  or 
handled  by  the  nurse,  except  that  a  naiTOW  strip  of  English  lint,  smeared 
with  vaseline,  may  be  laid  along  the  sutures  on  each  side  if  there  is  much 
soreness.  The  vagina  may  be  syringed  with  a  mild  carbolized  solution 
32 


498  GYNECOLOGICAL    OPERATIONS. 

once  daily  if  there  is  any  discharge,  care  being  taken  to  insert  the  tube  of 
the  syringe  so  as  not  to  touch  the  posterior  commissure.  If  there  is  no 
discharge,  and  there  should  not  be  if  the  wound  has  eyery  where  been  thor- 
oughly united  by  the  sutures,  these  douches  may  be  omitted.  The  peri- 
neum may  be  washed  by  irrigating  its  surface  seyeral  times  a  day.  Dur- 
ing these  manipulations  the  knees  may  be  slightly  separated.  After  each 
irrigation  iodoform  may  be  dusted  oyer  the  perineum  if  the  operator  has 
faith  in  this  antiseptic.  In  priyate  practice  I  neyer  use  it,  and  my  results 
haye  been  excellent. 

Usually  the  urine  has  to  be  drawn,  which  should  be  done  about  eyery 
six  hours,  the  urethra  being  exposed  by  yery  gently  separating  the  nymjDhse, 
and  the  yestibule  cleansed  before  inserting  the  catheter,  in  order  not  to 
cany  blood  or  purulent  matter  into  the  bladder.  If  the  patient  can  urin- 
ate herself,  I  generally  permit  it,  as  no  harm  can  happen  to  the  wound,  if 
it  is  well  closed,  by  simply  allowing  urine  to  flow  oyer  the  skin  of  the 
perineum.  Indeed,  some  of  my  best  results  have  been  obtained  in  cases 
where  no  catheter  was  used.  This,  however,  depends  on  the  patient's 
ability  to  urinate  herself.  Yery  many  women  find  it  impossible  to  do  so 
when  lying  on  the  back. 

The  bowels,  haying  been  thoroughly  evacuated,  can  be  left  dormant  for 
three  or  four  days,  unless  the^  manifest  a  desire  to  move  sooner,  when  an 
enema  of  soapsuds  and  warm  water,  with  some  sweet  oil,  should  be  given 
to  ensure  a  soft  (not  fluid)  movement.  If  there  has  been  no  desii'e  up  to 
the  fourth  day,  a  mild  laxative  should  be  given  at  night,  and  at  the  first 
sign  of  impending  action  the  above  enema.  It  should  be  remembered 
that  it  is  imperative  that  the  passage  should  be  perfectly  soft  and  smooth, 
absolutely  without  hard  concretions,  and  unattended  by  jDain;  further, 
that  next  in  danger  for  the  new  perineum  to  a  hard  passage  with  straining, 
is  a  diarrhea  with  straining.  The  latter  action — straining — is  to  be  abso- 
lutely avoided.  In  case  of  need,  oxgall  capsules,  gr.  v.  each,  may  be  given 
every  three  hours  for  twenty-four  hours,  followed  by  an  enema  of  equal 
parts  of  fresh  oxgall  and  soapsuds,  or  infusion  of  inspissated  oxgall  (  3  j. 
to  1  pmt  warm  water),  to  soften  concretions  ;  and  if  such,  or  a  thick  putty- 
like accumulation  is  found  in  the  rectum,  the  nm-se,  or  preferably  the 
operator,  must  break  the  mass  up  and  remove  it  with  the  fingers.  Unless 
the  narse  is  in  the  highest  degree  reUable,  the  operator  will  always  do  well 
io  attend  to  the  first  movement  of  the  bowels  himself,  as  it  is  then  that  the 
danger  of  relaceration  or  non-union  presents  itself,  even  though  the  stitches 
are  still  in  situ. 

Formerly  the  general  practice  was  to  constipate  the  bowels  until  after 
the  stitches  had  been  removed,  and  then  to  try  to  soften  and  remove  the 
accumulation  of  a  week  or  longer.  In  this  endeavor,  the  newly  healed 
perineum  often  suffered  ;  and  at  present  the  majority  of  operators  prefer 
to  allow  the  thoroughly  emptied  bowels  to  rest  .for  a  few  days  after  the 
operation,  but  then  to  have  them  emptied  gently  every  day  or  every  other 
day  until  the  stitches  are  remoyed.  It  is  particularly  after  operations  for 
complete  laceration  that  this  question  of  evacuating  the  bowels  comes  into 


OPERATION  OF  SECONDABY  PERINEORRHAPHY.     490 

prominence,  and  it  will  be  referred  to  again  in  that  section.  The  diet  for 
the  first  few  days  should  be  nutritious,  but  fluid  ;  after  the  bowels  have 
been  regulated,  everything  except  articles  likely  to  cause  flatulence  may  be 
allowed.  Stimulants  are  not  necessary,  although  there  is  no  special  ob- 
jection to  them.  Milk  should  be  avoided  until  after  the  bowels  have  been 
moved,  as  it  produces  caseous  excreta. 

Removal  of  Sutures. — The  bowels  having  been  thoroughly  moved  the 
day  before,  on  the  tenth  day  (if  there  is  suppuration  or  cutting  of  the 
sutures,  a  day  or  two  sooner)  the  stitches  are  removed.  The  patient  is 
placed  in  the  same  position  as  during  the  operation,  but  the  legs  are  kept 
nearly  in  apposition  and  are  held  over  the  head  of  the  operator,  with  knees 
and  thighs  flexed  at  a  right  angle.  Cutting  all  the  wires  with  one  stroke 
of  the  scissors,  they  are  liberated  from  the  rubber  tubing.  The  lowest 
wire  is  then  seized  with  the  dressing-forceps  and  gently  drawn  upon  until 
the  shining  silver  of  its  loop  becomes  visible  close  to  the  shaft  ;  this  is 
clipped  and  the  suture  gently  withdrawn  over  the  line  of  union,  that  is, 
toward  the  side  on  which  the  wire  was  cut.  While  doing  this  the  left 
hand  approximates  the  nates  to  prevent  tension  on  the  wound.  Thus 
suture  after  suture  is  removed,  unless  for  fear  of  tension  it  appears  safer 
to  remove  the  sutures  alternately.  But,  as  a  rule,  if  the  sutures  have  been 
left  in  ten  days,  either  the  perineum  is  firmly  united  or  the  operation  is  a 
failure.  Of  course,  care  should  be  taken  not  to  cut  off  the  shaft  of  the  sut- 
ure at  its  very  base,  which  may  easily  happen  when  a  suture  is  deej^h'  em- 
bedded ;  if  this  accident  should  occur  it  will  be  almost  useless  at  that  time 
to  seek  to  find  the  hidden  suture,  although  of  course  the  attempt  should 
be  made.  Too  much  exploring  may  do  more  harm  than  leaving  the  suture 
in  a  week  or  two  longer,  until  perfectly  solid  union  has  resulted.  If  pre- 
ferred, the  sutures  may  be  removed  with  the  patient  lying  on  her  side, 
when  the  perineum  is  sometimes  more  accessible.  After  removing  all  the 
stitches,  the  legs  are  again  bound  together  and  the  same  regimen  is  con- 
tinued as  before  for  three  or  four  days,  until  the  suture-canals  are  closed. 
The  bowels  are  not  moved  for  thirty-six  hours  after  removing  the  sutures. 
After  the  fourteenth  day  from  the  operation,  if  everything  has  gone  well, 
the  patient  may  be  allowed  to  sit  up,  soon  she  may  walk  about,  and  in 
three  weeks  from  the  operation  she  ought  to  be  in  fit  condition  to  be  dis- 
charged. For  a  couple  of  months  she  will  do  well  to  keep  the  perineum 
well  greased  with  vaseline  to  prevent  possible  ci-acking  of  the  fresh  cica- 
trix ;  the  bowels  should  be  kept  well  regulated,  and  coition  should  not  be 
indulged  in  before  two  months  at  the  earhest,  the  perineum  and  vagina 
being  vaselined  beforehand.  A  couple  of  years  should  be  allowed  to 
elapse  before  the  new  perineum  is  put  to  the  test  of  parturition. 

Operation  for  Complete  Laceration.— As  easy  as  is  the  performance  of  par- 
tial perineorrhaj)hy  and  as  favorable  as  are  usually  its  results,  so  difficult 
and  complicated  is  generally  the  operation  for  complete  laceration,  and  so 
frequently  is  it  Hable  to  be  followed  by  failure.  As  already  described,  the 
rent  extends  through  the  sphincter  ani,  which  retracts  sharply  to  either 
side,  and  more  or  less  up  the  recto-vaginal  septum.     We  have  therefore 


500 


GYNECOLOGICAL    OPEKATIONS. 


not  only  to  vivify  and  close  the  rent  in  the  perineum  proper  (as  in  the 
partial  operation),  but  also  that  in  the  septum,  and  to  attach  together  the 
separated  fibres  of  the  sphincter  ani,  both  of  which  objects  are  subject  to 
difficulties  and  causes  of  failure  peculiar  to  the  location  and  functions  of 
the  parts.  Thus  during  the  first  evacuation  of  the  bowels  both  the  septum 
and  the  sphincter  may  be  torn  open ;  or  the  retraction  of  the  fibres  of  the 
sphincter  may  be  such  as  to  render  all  efforts  to  approximate  or  retain 
them  in  apposition  by  sutures  futile.  And  if  the  sphincter  is  not  restored 
to  its  integrity  and  its  f mictions  are  not  regained,  the  great  object  of  the 
operation,  the  restoration  of  fecal  and  gaseous  continence,  is  missed,  even 
though  the  rent  in  the  septum  may  have  healed. 


Pig.  273, — Area  of  Denudation  in  Com- 
plete Laceration  of  Perineum.  S  a,  H  a, 
separated  ends  of  torn  sphincter  ani ;  res, 
fissure  in  recto- vaginal  septum  (P.  F.  M.). 


Fig.  273. — Shape  of  Denudation  for  Complete 
Perineorrhaphy  (Hegar  &  Kaltenbach). 


The  steps  of  the  complete  operation  are  these  :  1,  Denudation  of  the 
perineal  laceration  (as  in  partial  rupture)  ;  2.  Extension  of  the  perineal 
denudation  to  either  side  of  the  anus  so  as  to  include  the  cicatrix  covering 
the  separated  ends  of  the  torn  sphincter  ani  muscles  ;  3.  Still  further  ex- 
tension of  the  denudation  (if  required)  along  the  rent  in  the  recto-vaginal 
septum ;  and  4.  Apposition  of  all  these  denuded  surfaces  (perineum, 
sphincter  ani  fibres,  and  torn  recto-vaginal  septum)  by  sutures. 

The  preparation  of  the  patient  is  conducted  on  precisely  similar  princi- 
ples as  for  the  partial  operation.  But,  if  there  should  be  a  catarrhal  condi- 
tion of  the  rectum  or  diairhea,  it  would  be  well  to  subdue  the  former  by 
applications  of  a  solution  of  nitrate  of  silver,  ten  to  thirty  grains  to  the 
ounce,  and  iodoform  and  tannin  suppositories  ;  and  the  latter  by  bismuth 
and  opium,  castox'-oil  followed  by  Squibb's  fluid  extract  of  ipecac  and  opium 
in  frequently  repeated  drop  doses,  etc.,  before  operating.  The  rules  for 
preliminary  evacuation  of  the  bowels,  already  given,  should  be  followed 
with  special  thoroughness. 


OPERATION    OF    SECONDAEY    PERINEORRHAPHY. 


501 


Details  of  Operation. — The  method  usually  employed  in  this  counti*y  is 
that  described  by  Emmet,  and  consists  in  drawing  the  ends  of  the  torn 
sphincter  ani  together  by  sutures  which  begin  outside  of  the  separated 
ends  and  pass  around  the  rent  in  the  septum  close  to  the  vivified  ed^e. 
On  being  twisted  the  ends  of  the  sphincter  and  the  edges  of  the  septal 
rent  are  approximated.  The  diagrams  (Figs.  274,  275,  276),  taken  from 
Emmet,  illustrate  the  principle  on  which  these  sutures  act.  The  remain- 
ing sutures  are  then  inserted  precisely  as  for  partial  laceration. 

The  patient  occupying  the  same  position  as  for  ordinary  perineorrha- 
phy, the  operator  proceeds  in  the  same  manner  to  denude  the  left  side  of 
the  vulva  down  to  the  anus,  but  then,  instead  of  carrying  the  vivification 


Pig.  274.— First  Step.     C,  D,  first  suture ; 
A,  B,  second  suture. 


Fig.  275.— Second  Step. 


Fig.  276.— Third  Step. 


Diagrammatic  Sketches  representing  Introduction  of  Sutures  and  Approximation  of  Ends  of  Tom 
Sphincter,  according  to  Emmet. 

immediately  across  to  the  right  side,  he  trims  off  the  cicatricial  tissue  to 
the  left  of  the  gaping  anus  in  accordance  with  the  extent  of  the  cicatrix 
(see  Fig.  272),  and  then  carefully  pares  the  edge  of  the  rent  in  the  recto- 
vaginal septum  up  to  its  angle,  vivifying  not  only  the  edge  of  the  vaginal 
mucous  membrane,  but  also  that  of  the  rectum  and  the  cicatricial  border 
between  them. 

Some  operators  object  to  freshening  the  rectal  mucosa,  on  account  of 
the  rather  free  oozing,  but  I  think  the  broader  the  raw  surface  the  better 
the  chance  of  adhesion  by  first  intention.  The  denudation  is  then  carried 
down  the  right  side  of  the  triangle  representing  the  septal  fissure,  the 
cicatricial  tissue  covering  the  right  end  of  the  sphincter  muscle  is  trimmed 
off,  and  the  vivification  carried  up  on  the  right  labium  to  correspond  to 
the  left  side.     Every  particle  of  skin  or  mucous  membrane  which  might 


502  GYJS'ECOLOGICAL    OPEEATIOIS'S. 

interfere  with  ready  union  should  be  carefully  trimmed  away  from  about 
the  anus,  so  that  when  the  two  points  Sa  and  Sa  (Fig.  272)  are  brought  to- 
gether there  shall  be  absolute  symmetry  and  apposition.  The  next  strip 
of  tissue  trimmed  off  carries  the  viviiication  from  the  border  of  the  septal 
rent  into  the  vagina,  and  strip  after  strip  is  removed  precisely  as  in  the 
pai-tial  operation,  until  the  limit  traced  on  the  posterior  vaginal  w^all  is 
reachecf.  Fig.  272  represents  the  usual  appearance  of  the  wound  in  an 
operation  of  this  kind.  In  trimming  about  the  anus,  care  should  be  taken 
not   to   wound   hemorrhoids,  which   are   not  uncommon  in  these  cases. 

The  first  suture  is  passed  as  shown 
in  Fig.  277.  If  it  is  not  inserted  and 
brought  out  well  behind  the  outer 
border  of  the  anus,  it  will  miss  the 
end  of  the  sphincter,  and,  while  the 
perineum  will  be  perfect,  the  ojoera- 
tion  will  be  a  failure  because  there 
will  be  a  gap  or  fissure  in  the  median 
line  (see  Fig.  276)  where  the  torn  ends 
of  the  sphincter  were  not  brought 
together,  and  hence  failed  to  unite  : 
continence  has  not  been  achieved. 
This  first  suture  is  earned  just  under 
the  surface  to  the  uj)per  angle  of  the 
rent,  there  the  needle  (a  short  one) 
is  brought  out  and  immediately  rein- 
serted at  the  same  spot  and  carried 
down  the  other  side,  and  brought  out 

Co^feteTa^^tLrCafteJ^Halt""^^^^^^  ^^    ^    poiut    Corresponding    to    its    en- 

vaginal  septum.  trance.    Suture  No.  2  lies  close  outside 

of  the  first,  and  then  the  remaining  sutures  are  passed  in  the  usual  manner. 

If  it  is  thought  desii'able,  on  account  of  obtaining  a  more  correct  idea 
of  the  extent  of  the  wound  and  the  number  of  sutures  still  required,  the 
rectal  rent  may  be  closed  at  once  by  twisting  the  first  two  sutures,  but 
generally  I  twist  them  all  at  the  end.  It  is  rare  to  require  more  than  two 
of  these  semicircular  sutures  to  close  any  rectal  rent  which  should  be 
treated  by  this  foi-m  of  suture.  If  the  first  suture  has  been  well  applied, 
on  twisting  it  its  junction  will  be  carried  Avithin  the  sphincter.  Figs.  277 
and  278,  modified  from  cuts  by  H.  T.  Hanks  {Medical  Record,  July  1, 
1882),  give  a  very  good  representation  of  the  course  of  the  sutures  and 
the  approximation  of  the  rent  in  the  septum  as  the  first  sutures  are  twisted. 

The  after-treatment  resembles  that  already  described,  except  that  flatus 
may  require  the  repeated  insertion  into  the  rectum  of  a  slender  tube  (Hke 
the  child's  nozzle  of  a  Davidson  syringe),  a  procedure  requiring  great  deli- 
cacy of  touch  in  order  not  to  disturb  the  sutures ;  and  that  special  pains 
must  be  taken  to  have  the  bowels  loose  and  smooth.  On  the  success  of 
the  latter  function  usually  depends  the  entire  success  of  the  operation. 
The  sutures  are  removed  as  already  described. 


OPERATION    OF    SECONDARY    PERINEORRHAPHY. 


503 


For  weeks  afterward  the  utmost  care  should  be  observed  to  secure 
regular  soft  fecal  evacuations,  until  the  new  sphincter  has  had  time  to 
regain  its  full  power. 

Simon's  Operation  for  Complete  Laceration. — The  operation  of  Emmet 
is  chiefly  applicable  to  cases  where  the  laceration  does  not  extend  higher 
than  an  inch  up  the  recto-vaginal  septum.  It  is  obvious  that  a  fonn  of 
suture  which,  when  perma- 
nently twisted,  necessarily 
puckers  together  the  edges 
of  the  rent  (like  the  cord 
around  the  mouth  of  a  bag), 
will  not  secure  so  smooth 
apposition  when  the  rent 
is  two  inches  long  as  when 
it  is  less  than  one  inch  long. 
It  is  true  that  I  have  in  sev- 
eral instances  succeeded  ad- 
mirably with  Emmet's  sut- 
ure, although  the  rent  ex- 
tended nearly  two  inches  up 
the  septum  ;  but  several 
times  the  sphincter  failed 
entirely  to  unite,  and  sub-  J^  "Y  •■^'' 
sequent    cauterization   was 

required  to  close  the  defect  ;      Fig.  27s.— Method  of  Twisting  sutures  in  Complete  Laceratioa 

and  in  two  instances  a  recto-  ^''''^'  '"''^'^-   ^  ^  ''•  -=*°-^-i  -p'"-- 

vaginal  fistula  remained,  although  the  perineum  itself  was  perfect. 

For  deep  lacerations  of  the  septum  extending  over  an  inch  above  the 
sphincter,  particularly  with  prolapse  of  the  rectal  mucous  membrane,  a 
different  operation  is  advisable,  which  consists  in  sewing  together  the 
edges  of  the  rectal  fissure  separately,  including  the  ends  of  the  torn 
sphincter,  tying  the  sutures  in  the  rectum,  and  then  doing  ordinary  perine- 
orrhaphy. These  two  operations,  proctorrhaphy  or  the  rectal  suture,  and 
perineorrhaphy  or  the  perineal  suture,  may  be  done  successively  at  the  same 
sitting,  or  when  the  rectal  fissure  is  healed  the  perineum  may  be  sewed. 
In  the  latter  case  the  sutures  may  as  well  be  tied  in  the  vagina,  as  the 
gaping  perineum  will  pei'mit  of  their  easy  removal  through  that  passage. 
But  I  have  followed  the  lead  of  Simon,  to  whom  the  credit  is  due  of  having 
first  elaborated  and  popularized  this  operation,  and  have  performed  both 
steps  at  the  same  sitting.  The  special  point  about  the  rectal  sutures  is  so 
to  insert  them  that  they  grasp  only,  but  all,  the  denuded  I'ectal  mucous 
membrane,  and  do  not  include  the  vaginal  mucosa.  They  are  passed  from 
the  rectum  on  one  side  through  the  border  of  the  denuded  rectal  mucous 
membrane,  brought  out  just  beneath  the  border  of  the  denuded  vaginal 
mucous  membrane,  carried  over  to  the  other  side  of  the  rent,  and  retm-ued 
to  the  rectum  in  precisely  the  same  manner.  Each  suture  is  tied  and  cut 
short  in  the  rectum  as  soon  as  passed.     When  thus  tied  in  the  rectum 


504 


GYNECOLOGICAL    OPEEATIONS. 


these  sutures  will  accurately  approximate  only  denuded  surfaces  ;  but  if 
they  had  been  carried  out  into  the  vagina  and  back  again  in  the  same  man- 
ner, the  undenuded  edge  of  the  vaginal  mucous  membrane  would  have 
been  rolled  into  the  rent  and  would  have  interfered  with  union.  When 
these  rectal  sutures  have  been  tied  the  edges  of  the  vaginal  mucous  mem- 
brane are  united  by  a  row  of  fine  superficial  sutures,  each  of  which  is 
tied  immediately  after  insertion,  and  perfect  apposition  will  thus  be  ob- 
tained. A  reference  to  Fig.  280  will  explain  the  position  and  relations  of 
these  rectal  and  vaginal  sutures.  When  the  rent  in  the  septum  has  thus 
been  united,  the  perineal  laceration  has  become  almost  effaced,  and  merely 
superficial  sutures  are  requu'ed  to  bring  together  the  skin  and  supei-ficial 
fascia.  The  rectal  and  vaginal  sutures  may  be  either  of  fine  twisted  or 
braided  disinfected  silk,  the  rectal  sutures  being  both  cut  short,  or  one 


rmn 


Fig.  279.— Introduction  of  Rectal  and  Vaginal 
Sutures  in  Simon's  Colpo-perineorrhapliy. 


Pig.  280.— Section  View  of  Sutures 
in  Simon's  Operation.  V,  vagina;  R, 
rectum ;  P,  perineum. 

end  only  is  carried  out  of  the  rectum,  and  all  are  tied  in  a  knot ;  or  of  fine 
catgut,  which  are  tied  and  cut  short  as  soon  as  each  suture  is  passed,  and 
which  are  absorbed.  For  security  of  apposition  until  firm  union  is  ob- 
tained I  prefer  silk  ;  for  convenience  as  far  as  removal  is  concerned,  catgut 
has  the  advantage.  In  the  vagina  silver  wire  may  be  employed,  each 
suture  being  cut  short,  but  removed  in  several  weeks  ;  but  wire  must 
evidently  be  inconvenient  for  the  rectal  suture,  because  it  pricks  and  re- 
quires removal. 

In  inserting  the  rectal  sutures  the  silk  or  gut  may  be  armed  with  a  fine 
curved  surgical  needle  at  each  end,  and  is  then  passed  from  vagina  to  rec- 
tum ;  or,  what  is  quite  as  easy,  only  one  needle  is  used  and  is  passed 
around  the  circle  from  rectum  to  vagina,  and  back  again  through  the  other 
lip  into  the  rectum.  The  utmost  care  in  paring  and  apposition  must,  of 
course,  be  observed.  The  vaginal  sutures  are  passed  with  a  similar  thin 
cuYwed  surgical  needle  and  cut  short.  Both  series,  rectal  and  vaginal, 
may  be  allowed  to  cut  their  way  out,  if  silk  ;  but  it  is  just  as  well  to  remove 


OPERATION    OF    SECONDARY    PERINEORUKAPHY. 


505 


the  rectal  sutures  with,  fine  scissors  on  the  tenth  to  fifteenth  day,  if  they 
are  perfectly  loose.  Recent  operators  cut  the  silk  sutures  short  in  the  rec- 
tum also,  and  let  them  cut  out  at  will,  and  I  think  this  is  the  best  plan. 
The  perineal  sutures  can  be  either  wire  or  silk  ;  I  think  silk  will  probably 
do  as  well,  as  they  are  quite  superficial  when  the  recto-vaginal  rent  has 
been  united.  The  perineal  sutures,  of  course,  are  removed  like  silk  sutux'es 
elsewhere. 

In  one  instance  of  very  deep  rectal  rent,  after  uniting  the  rectal  mucosa 
by  catgut  sutures  tied  in  the  rectum,  I  brought  the  raw  surfaces  on  the 
posterior  vaginal  waU  together  by  very  fine  catgiit  sutures,  which  I  cut 
short  and  dropped  in  the  wound,  and  then  closed  the  vaginal  mucous 
membrane  and  the  perineum  over  them.  In  this  way  I  obtained  a  much 
wider  line  of  union  over  the  rent  in  the  rectal  wall,  and  guarded  against 
accidental  gaping  in  the  rectal  mucosa.     The  result  was  perfect  union. 


Fig.  281.— Introduction  of  Terineal  Sut- 
ures after  Closure  of  Septal  Rent  (P.  P.  M.). 


Fig.  282.— Section  View  of  Sutures  in  Rent  to  Vaginal 
Vault.     V,  vagina  ;  B,  rectum ;  P,  perineum  (^Kaltcnbach). 


Emmet's  New  Operation  for  Lacerated  Ferineum. — A  very  ingenious  and 
anatomically  correct  operation  for  lacerated  perineum  has  recently  been 
devised  by  Dr.  T.  A.  Emmet,  who  described  it  at  the  meeting  of  the  .Ajner- 
ican  Gynecological  Society  in  1883.  Since  then  it  has  attracted  the  at- 
tention of  numerous  physicians  who  have  seen  its  author  perform  it  at  the 
Woman's  Hospital,  and  it  will  doubtless  remain  one  of  the  established 
operations  in  gynecology. 

Starting  from  the  opinion  that,  to  restore  the  perineum  to  its  normal 
condition  and  strength,  it  is  necessary  to  reunite  the  fibres  of  the  peine 
fascia  which  were  torn  when  the  accident  occurred.  Dr.  Etnmet  denudes 
two  elliptical  surfaces  in  either  lateral  furrow  of  the  vagina,  beginning  at 
the  posterior  commissure  in  the  median  Ihie  or  posterior  columna  rugarum, 
and  extending  up  variably  from  two  to  three  inches.  The  limits  of  these 
two  lateral  denudations  are  the  internal  border  of  the  posterior  commis- 
sure, the  lowest  caruncle  of  the  hymen,  at  either  side,  and  the  crest  of  the 


506 


GYNECOLOGICAL    OPERATIONS. 


columna  rugarum  posterior,  or  rectocele,  in  the  centre.    The  edges  of  each 
lateral  wound  are  then  united  by  sutures,  which  are  carried  deep  into  the 

furrow  and  entirely  under  the  raw  sur- 
face, so  as  to  pick  up  the  separated  fibres 
of  the  pehdc  fascia.  When  first  one  side 
and  then  the  other  is  sutured,  there  re- 
mains only  a  very  shallow  slit  of  mucous 
membrane  in  the  median  hne  to  stitch 
together,  which  is  done  by  silk.  To  re- 
move the  stitches  it  is  only  necessary  to 
elevate  the  anterior  vaginal  wall  with 
Sims'  speculum. 

One  gTeat  advantage  of  this  operation 
is  that  the  denudation  is  carried  on  en- 
tirely within  the  vagina,  that  the  sutures 
are,  all  but  the  last  few  superficial  ones, 
internal,  and  that  the  pain  always  attend- 
ing the  old  operation  of  perineorrhaphy, 
which  is  in  j)art  a  cutaneous  operation, 
is  avoided. 

By  taking  in  the  redundancy,  or 
"slack,"  of  the  joosterior  vaginal  waU  the 
new  operation  effectually  narrows  the  va- 
gina without  destroying  the  normal  me- 
dian fold,  as  does  Simon's  oj)eration  for 
posterior  colporrhajjhy.  In  this  respect 
this  new  departure  of  Emmet  is  undoubt- 


FiG.  283.— Shape  and  Site  of  Denudation 
in  Emmet's  Kew  Operation  for  Lacerated 
Perineum  (P.  F.  ilj. 


Fio.  284.— Shape  of  Denuda- 
tion in  Emmet's  New  Operiition 
for  Lacerated  Perineum,  show-ingr 
Edges  to  be  united  by  Sutures  1 
to  1,  2  to  2.  3  to  3,  4  to  4.  R,  tip 
of  undenuded  strip  on  posterior 
vaginal  wall,  to  be  united  to 
opposing  point  of  perineum  (P. 

F.  JI.).  T?  CO- 

Fig.  28o.— Shape  of  Denudation  in  Emmet's  Xew  Operation  for 
Lacerated  Perineum  as  seen  when  Tip  of  Rectocele,  R,  is  lifted  up  by 
a  ienacijlum  during  Paring  and  Introduction  of  Sutures  (P.  F.  M.). 

edly  preferable.  In  fact,  it  is  a  most  exceUent  operation  for  rectocele,  and 
It  IS  extremely  probable  that  it  also  fulfils  the  purpose  for  which  it  was 
devised,  namely,  of  reunitmg  the  torn  pelvic  fascia  and  thereby  restoring 


OPERATION    OF    SECONDARY    PERINEORRHAPHY. 


5or 


the  strength  of  the  perineum.  But  in  so  far  it  seems  to  me  to  fail,  as  an 
operation  for  laceration  of  the  perineum,  in  that  it  does  not  restore  the 
vulva  to  its  pre-parturient  condition  ;  the  vulvar  cleft  and  vaginal  orifice 
continue  to  gape,  the  fourchette  is  still  wanting,  and  if  the  laceration  was  a 
deep  one  the  posterior  vaginal  Avail  slopes  down  in  proportion  toward  the 
sphincter  ani.  Of  course,  the  rectocele  is  entirely  and  effectually  removed, 
but,  so  far  as  I  can  see,  in  deep  lacerations  more  is  needed,  and  hence  I  do 
not  think  that  the  new  operation  can  supersede  the  old,  except  in  compara- 
tively slight  external  lacerations,  where  the 
redundancy  and  prolapse  of  the  posterior 
vaginal  wall  predominates  and  is  the  chief 
defect  to  be  remedied.  Whenever  the  peri- 
neal rent  itself  is  deep,  it  seems  to  me  that 
the  old  and  well-established  denudation  of 
the  labia  with  cutaneous  sutures  will  still 
be  needed,  either  alone,  or  if  there  be  a  rec- 
tocele, in  addition  to  the  new  intravaginal 
method.  A  recent  experience  with  this  new 
oj)eration  confirms  this  opinion,  since  a  sec- 
ond operation  for  the  restoration  of  the  nor- 
mal vaginal  outlet  appears  indicated  in  the 
case  referred  to.  The  similarity  of  Emmet's 
new  operation  to  that  of  Freund,  shown  in 
Fig.  292,  will  be  apparent  at  a  glance.  This 
operation  I  performed  for  large  rectocele 
several  times  two  or  three  years  ago ;  its 
essential  difference  is  that  the  skin  of  the 
labia  and  perineum  is  included  in  the 
denudation  and  the  sutures. 

It  should  be  added,  that  the  new  opera- 
tion is  not  adapted  to  complete  lacerations 
through  the  sphincter  ani. 

0perati07i  for  Central  Laceration. — "When 
this  rare  accident  is  met  with  in  its  chronic 
condition,  it  is  recognized  by  a  small  fistu- 
lous passage  between  vagina  and  perineum — a  perineo-vaginal  fistula. 
There  is  no  use  trying  to  cure  such  a  fistula  by  caustics  or  by  paring  and 
uniting  its  walls.  The  only  effectual  treatment  is  to  slit  it  open  from  the 
posterior  commissure  downward,  trim  out  the  cicatricial  tissue  in  the 
track  of  the  fistula,  and  unite  it  by  sutures  precisely  like  a  partial  laceration. 

Tertiarxj  Operation  for  Lacerated  Perineum.— li  the  secondary  opera- 
tions above  described  fail  to  achieve  complete  or  even  partial  union  of  the 
lacerated  parts,  the  necessity  for  a  still  further  operation  arises.  Failures 
after  complete  perineorrhaphy  are  not  uncommon,  and  many  an  operator 
has  seen  himself  compelled  to  repeat  the  attempt  three  or  four  times  before 
success  finally  crowned  his  efforts.  The  tertiary  operation  should  be  de- 
ferred until  perfect  cicatrization  of  the  recent  wound  has  taken  place,  and 


Fig.  2S6. — Emmet's  New  Opcnition  for 
Lncerateil  I'eriiionm.  Lateral  sutures 
twisted,  leaving  only  small  slit  ut  posterior 
commissure  unclosed.  One  circular  suture 
through  edge  of  labia  and  tip  of  rectocele, 
II,  and  several  superficial  transver.se  sut- 
ures are  waiting  to  be  twisted  (P.  F.  SI.). 


508  GYNECOLOGICAL    OPEEATIONS. 

in  the  meanwhile  the  patient's  general  health  should  be  built  up,  and  the 
local  tissues  put  in  as  good  condition  as  possible  for  plastic  union.  In 
performing  the  next  operation,  the  operator  should,  of  course,  endeavor 
to  eliminate  and  avoid  any  sources  of  failure  which  he  may  be  able  to 
discover  as  having  existed  in  the  previous  operation.  Among  such  may 
be,  neglect  to  have  the  bowels  properly  prepared  beforehand  and  at- 
tended to  afterward,  insufficient  denudation  and  imperfect  coaptation ; 
too  thick  or  too  thin  needles  or  sutures,  too  tight  twisting  of  sutures ; 
want  of  cleanliness  of  instruments  and  sponges  ;  general  anemia,  etc. 
In  the  large  majority  of  cases  the  failure  is  due  to  some  well-defined 
and  avoidable  neglect  or  error  before,  during,  or  after  the  operation. 
Occasionally,  however,  influences  beyond  the  immediate  control  of  the 
operator,  such  as  hospitalism,  abscesses  and  suppuration  along  the  sutures, 
accidents,  etc.,  may  be  at  fault.  If  a  large  recto-vaginal  fistula  remains,  the 
best  plan  is  generally  to  cut  through  the  newly  formed  perineum,  and  do 
the  whole  operation  over  again.  The  older  operators  fancied  that  unless 
the  sphincter  ani  were  paralyzed  after  perineorrhaphy,  its  contractions 
would  hinder  union  ;  hence  they  were  in  the  habit  of  dividing  it  posteriorly 
with  the  knife.  This  practice  is  now  entirely  obsolete,  at  least  so  far  as 
the  indications  of  paralysis  of  the  sphincter  is  concerned.  Hegar  favors 
bilateral  division  of  the  sphincter  after  bad  cases  of  operation  for  complete 
laceration,  in  order  to  permit  the  tioublesome  gases  to  escape  freely  dur- 
ing the  first  few  days  after  the  operation.  If  there  were  no  fear  of  perma- 
nent injury  to  the  sphincter  this  purpose  would  certainly  justify  the 
measure. 

Another  quite  obsolete  measure  was  to  make  long  and  deep  incisions 
on  each  side  of  the  perineum  to  relieve  tension.  When  I  have  thought  it 
necessary  to  relax  the  perineum  as  much  as  possible,  which  was  the  case 
only  in  tertiary  operations,  I  have  secured  all  the  relaxation  required  by 
drawing  the  nates  together  with  broad  strips  of  adhesive  plaster,  with  a 
hole  cut  in  the  centre  for  the  rectal  flatus-tube,  thi'ough  which  the  fluid 
fecal  evacuations  Avere  allowed  to  pass. 

The  coaptation  of  the  lips  of  the  wound  by  quills  or  bead-tubes, 
through  which  the  sutures  were  passed  before  being  tied,  has  been  aban- 
doned as  unnecessary  and  useless. 

Dangers  and  Evil  Results  of  Secondary  Perineorrhaphy.-— 1  have  often 
been  asked  the  question,  by  patients  and  their  friends,  whether  this  is  a 
dangerous  operation,  and  have  always  repHed  most  decidedly,  No.  On 
the  other  hand,  on  being  asked  whether  it  was  entirely  free  from  danger,  I 
have  felt  compelled  to  give  the  same  negative  answer.  In  itself,  perineor- 
rhaphy involves  no  danger  to  Hfe,  but,  hke  any  fresh  wound,  it  may  be  ex- 
posed to  certain  accidents,  such  as  hemorrhage,  inflammation,  suppuration, 
and  septic  infection,  which  may  more  or  less  endanger  the  health  or  life  of 
the  individual.  While  serious  accidents  are  rare,  I  doubt  not  that  one  or 
more  cases  of  septicemia,  even  with  fatal  termination,  might  be  found  re- 
corded in  literature,  and  I  myself  witnessed  a  simple  operation  for  complete 
laceration,  by  Dr.  B.  F.  Dawson,  of  New  York,  in  which  not  a  shadow  of 


OPERATION    OF    SECONDARY    PERINEORRII\PIIT.  509 

blame  could  be  attached  to  the  operator  for  want  of  care  or  dexterity,  but 
after  which  fatal  tetanus  developed. 

Hemorrhage,  at  the  time  of  the  operation,  is  seldom  serious ;  one  or 
two  arterial  twigs  may  be  cut  or  a  vein  may  be  punctured,  but  the  bleed- 
ing is  immediately  arrested  by  forceps,  and,  if  it  still  persists,  permanently, 
by  twisting  the  sutures.  Ligatures  are  seldom  required,  and  only  once  or 
twice  have  I  thought  it  wise  to  tie  the  vessel  with  catgut,  which  was  cut 
short  and  dropped.  Secondary  hemorrhage  rarely  occurs,  because  there 
are  no  vessels  of  importance  injured  during  the  operation,  and  it  can  easily 
be  checked  by  cold  or  pressure. 

Inflammation  along  the  track  of  the  sutures,  and  edema  of  the  lips  of 
the  wound  is  not  very  uncommon.  It  ma}-  be  due  to  bruising  by  artery- 
forceps  during  the  operation,  to  too  many  or  too  tight  sutures,  to  inclusion 
of  blood  in  a  pocket  in  the  wound  (as  when  the  sutures  are  not  kept  well 
under  the  raw  surface),  and  to  the  irritation  of  the  sutures.  I  have  thus 
seen  celluhtis  terminating  in  abscess  in  the  ischio-rectal  fossa,  inflamma- 
tory edema  and  suppuration  in  the  lips  of  the  wound,  the  pus  bursting 
either  outward  through  the  skin,  or  inward  through  the  mucous  membrane 
of  the  vagina  or  rectum. 

Septic  infection  from  enclosed  pus  in  any  part  of  the  wound  may  take 
place.  I  have  never  seen  it ;  but  instances  have  come  to  my  knowledge 
where,  under  peculiarly  unfavorable  atmospheric  influences,  rigors  followed 
by  a  rise  of  temperature  indicated  septicemia,  and  called  for  the  removal 
of  the  sutures  and  the  leaving  open  and  thorough  disinfection  of  the 
wound.  Inflammatory  reaction  and  septic  infection  are  more  likely  to 
occur  in  hospitals  than  in  private  practice.  Hence  it  has  been  my  custom 
to  keep  the  perineum  and  vaginal  orifice  thoroughly  dusted  with  finely 
powdered  iodoform  after  every  perineorrhaphy  in  the  hospital,  until  the 
stitches  have  been  removed  and  union  found  perfect. 

Extreme  care  in  cleansing  the  wound  of  coagula  and  in  coajDtating  its 
surfaces,  so  as  to  avoid  the  formation  of  ^Dockets  or  furrows,  as  well  as 
observance  of  thorough  antisepsis  in  everything  pertaining  to  the  opera- 
tion, are  the  means  to  prevent  septic  infection. 

If  the  inflammatory  edema  of  the  wound  is  but  moderate,  no  interfer- 
ence but  iodoform  dusting,  and  perhaps  vaseline  strips,  is  required.  Ex- 
cessive edema,  involving  bursting  of  sutures,  may  require  their  entire  or 
partial  removal ;  or  the  wire  loops  may  be  simply  cut,  so  as  to  relieve  ten- 
sion, but  the  suture  left  as  a  sort  of  a  sphnt  for  several  days  longer.  Edema 
of  the  tissues  about  the  anus  soon  after  the  operation  is  often  a  source  of 
great  annoyance  to  the  patient,  even  in  partial  ruptures,  and  relief  may  be 
given  by  an  ice  poultice  during  the  first  forty-eight  hours,  or,  if  the  edema 
persists,  by  simply  cutting  the  loop  of  the  suture  nearest  the  anus.  After 
the  bowels  have  been  moved  this  edema  usually  disappears. 

Of  the  evil  results  occasionally  following  the  operation  the  most  frequent 
and  annoying  is  the  formation  of  pus  along  the  track  of  the  wound  or  the 
stitches,  and  its  evacuation  either  into  the  vagina  or  rectum,  or  between 
the  stitches  through  the  perineal  wound.     In  the  one  case  we  have  a  recto- 


510  GYNECOLOGICAL    OPERATIONS. 

vaginal  fistula,  and  in  the  other  a  perineo-vaginal  or  perineo-rectal  fistula. 
The  worst  accident,  by  all  odds,  is  the  perforation  by  the  pus  of  the  recto- 
vao-iual  septum  ;  the  perineum  may  be  perfect,  but  the  operation  is  a 
faihu-e,  since  air  and  fecal  matter  pass  into  the  vagina  through  the  fistula. 
If  the  opening  is  small  it  very  often  closes  spontaneously  in  the  course  of 
a  few  weeks,  or  it  is  healed  by  lunar  caustic,  and  a  cure  is  established. 
Hence  it  is  well  for  the  operator  not  to  express  himself  at  once  too  posi- 
tively when  he  suspects  a  failure  of  his  operation,  for  two  or  three  weeks 
may  produce  so  satisfactory  a  result,  as  to  continence,  that  the  patient  her- 
self may  never  be  aware  how  near  she  was  to  failure.  But  if  the  fistula  is 
large,  that  is,  of  sufficient  size  to  admit  a  lead-pencil,  it  is  very  unlikely  to 
close  by  itself,  and  the  best  measure  undoubtedly  is  in  due  time  to  sj)lit 
the  whole  perineum  open  again,  however  cruel  to  the  patient  and  annoy- 
ing to  the  operator  this  may  seem,  and  do  the  operation  over  again.  It  is 
generally  a  waste  of  time  and  trouble  to  try  to  close  a  recto-vaginal  fistula 
by  paring  its  edges  and  bringing  them  together  by  sutures.  Even  though 
the  mucous  membrane  of  the  vagina  is  made  to  unite,  a  pocket  is  left  in 
the  septum  into  which  feces  pass  from  the  rectum,  and  sooner  or  later  the 
fistula  reopens.  Simon  had  some  success  in  closing  these  fistulee  from  the 
rectum,  which  was  everted  by  the  fingers  of  an  assistant  in  the  vagina,  but 
complete  union  is  exceptional. 

h.  per Ineo-vaginal  fistula  is  not  nearly  so  bad,  and  usually  closes  spon- 
taneously or  on  cauterization.  Even  if  left  open  it  produces  no  special 
annoyance,  and  I  should  hardly  think  of  splitting  the  septum  between  the 
perineal  opening  and  the  posterior  commissure,  and  repeating  that  portion 
of  the  perineorrhaphy,  unless  the  band  of  tissue  anterior  to  the  perineal 
opening  was  very  narrow.  The  efficiency  of  the  new  perineum  as  a  whole 
would  settle  the  question  as  to  whether  it  required  additional  strengthen- 
ing or  not. 

A  recto-perineal  fistula  is  a  more  serious  matter  than  a  vagino-perineal, 
because  rectal  discharges  will  escape  through  it,  but  if  minute  it  occasions 
httle  annoyance.  If  troublesome,  it  should  be  slit  through  the  sphincter 
and  healed  by  caustics.  To  sew  it  together  does  but  little  good,  as  the 
space  is  too  small  to  accommodate  the  number  of  stitches  required.  Such 
fistulse  should  be  treated  like  ordinary  anal  fistulse  in  either  sex. 

A  very  annoying  accident  in  deep  complete  lacerations  is  the  failure  of 
the  sphincter  muscle  to  unite.  If  the  anus  gapes  at  all,  the  rectal  mucous 
membrane  is  liable  to  prolapse,  and  the  condition  is  but  Httle,  if  any,  bet- 
ter than  before  the  operation.  It  is  of  little  use  to  try  to  restore  that  por- 
tion of  the  perineum,  because  so  many  sutures  are  required  to  bring  the 
spliincter  in  apposition  that  they  crowd  each  other  and  produce  suppm-a- 
tion  or  cut  out.  I  have  been  obliged  in  one  case,  after  failing  with  this 
plan,  to  slit  the  whole  perineum  open  again  and  begin  anew. 

Small  fissures  at  the  anterior  margin  of  the  anus  can  usually  be  healed 
by  the  stick  of  nitrate  of  silver  and  iodoform  powder,  and  the  sphincter 
restored  to  very  fair  power. 

In  three  instances  a  cellulitis  and  abscess  in  the  ischio-rectal  fossa  de- 


OPERATION-    OF    SECONDARY    PERmEORRHAPHT.  511 

veloped,  which  were  poulticed,  and  twice  1  succeeded  in  causing  the  pus 
to  point  toward  the  skin  just  inside  of  the  tuber  ischii,  where  I  evacu- 
ated it  with  the  knife  ;  in  the  third  instance  the  abscess  burst  through  the 
perineal  wound,  and  the  sinus  speedily  closed.  The  sutures  were  not  re- 
moved  until  the  cellulitis  had' all  disappeared,  and  all  three  cases  made 
good  recoveries. 

Not  uncommonly  the  skin  fails  to  unite  at  some  point  of  the  perineal 
wound,  and  a  pocket  remains  after  the  sutures  are  removed,  which  usually 
closes  spontaneously  witliin  a  week.  After  removing  the  sutures  the  skin 
of  the  new  perineum  usually  appears  elevated  in  ridges  and  nodules  be- 
tween each  two  sutures,  and  the  perineum  has  a  rough,  decidedly  unnatu- 
ral appearance.  The  operator  can  console  himself  and  the  patient  by  the 
assurance  that  a  few  weeks  Avill  efface  all  these  irregularities,  and  that  the 
skin  will  become  almost  as  smooth  as  before  the  original  rupture. 

Besides  the  danger  of  giving  rise  to  accumulation  of  blood  and  pus  be- 
tween the  surfaces  of  the  wound,  the  formation  of  pockets,  by  allowing 
the  suture  to  protrude  at  some  portion  of  the  denudation,  has  another,  al- 
though less  serious,  consequence,  namely,  the  gradual  develojjment  of 
small  cysts  containing  sero-purulent  fluid  in  the  substance  of  the  new  peri- 
neum. This  develojDment  may  also  be  due  to  the  accidental  leaving  of 
small  islands  of  undenuded  tissue  in  the  wound,  which  continue  to  secrete 
the  serous  discharge  peculiar  to  the  vagina.  These  little  cysts  are  usually 
found  in  the  median  line,  and  feel  like  movable  gi-apes  between  the  skin 
of  the  perineum  and  the  vagina,  I  have  had  two  such  instances  among 
my  earlier  cases.  In  the  second  instance  the  lady  became  pregnant,  the 
cyst  grew  rapidly,  and  attained  the  size  of  an  English  walnut.  Just  be- 
fore labor  I  incised  it  and  cauterized  its  interior  with  tr.  iodine,  and  fortu- 
nately it  did  not,  as  I  had  feared,  interfere  with  the  distention  of  the  peri- 
neum. In  the  other  case  I  incised  the  cyst  and  obliterated  it  by  thoroughly 
burning  it  with  solid  nitrate  of  silver. 

As  a  rule,  in  cases  where  everything  is  going  on  well,  there  is  no  rise 
of  temperature  after  a  perineorrhaphy ;  should  such  occur,  and  the  patient 
complain  of  pain  and  throbbing  in  the  wound,  especially  about  the  third 
to  fifth  day,  it  is  well  to  iusiDect  the  perineum  and  gently  touch  its  sides, 
for  either  inflammatory  edema  of  the  wound,  or  cellulitis  in  the  flaps,  or 
suppuration  is  taking  or  has  taken  place  somewhere  in  the  wound.  If 
then  the  temperature  drops,  the  pain  subsides,  and  pus  is  found  oozing 
from  the  vagina,  rectum,  or  between  the  perineal  sutures,  the  presence  of 
an  abscess  is  assured.  Else  of  temperature,  then,  and  pain  several  days 
after  subsidence  of  the  soreness  immediately  following  the  operation,  are 
symptoms  to  be  watched  and  feared.  From  what  I  have  said  in  the  pre- 
ceding pages,  it  will  appear  that  while  edema,  cellulitis,  and  suppuration 
are  annoying  and  disquieting  circumstances,  tlieir  occurrence  by  no  means 
indicates  that  the  operation  is  to  be  a  total  failure,  since  small  perforations 
and  pockets  may  all  eventually  heal  spontaneously  and  an  ultimate  good 
result  be  obtained.  Primary  union,  it  is  true,  may  not  be  perfect,  but  a 
practical  success  is  often  assured  by  the  aid  of  granulation  and  cicatrization. 


512  GYNECOLOGICAL    OPERATIONS. 

Failures. — The  preceding  pages  already  contain  tlie  causes  and  pre- 
vention of  the  failures  of  secondary  perineorrhaphy.  It  seemed  more  con- 
venient to  discuss  these  points  while  speaking  of  the  evil  results  liable  to 
follow  the  operation,  which  constitute  in  the  main  the  sources  of  total  or 
partial  failure.  It  has  been  seen  that  the  majority  of  these  causes  may  be 
attributed  to  the  operator  or  the  method  of  operation,  some  to  the  consti- 
tution and  carelessness  of  the  patient,  and  some  to  influences  (atmosjDheric, 
telluric)  not  under  the  control  of  either  operator  or  patient.  One  of  my 
failures,  in  a  case  of  large  complete  laceration,  was  due  to  the  patient's 
having,  unknown  to  me,  swallowed  a  prune-stone  several  days  before  the 
operation  ;  this,  unfortunately,  had  not  come  away  before,  but  during  one 
of  the  fii-st  movements  of  her  bowels,  when  union  seemed  perfect,  wedged 
itself  crosswise  into  the  new  anus,  and  tore  out  the  wires  holding  together 
the  ends  of  the  sphincter.  While  the  rest  of  the  perineum  was  perfect, 
the  anus  gaped  widely. 

The  proportion  of  failures  after  partial  perineorrhaphy  is  small.  Out 
of  my  first  sixty-five  cases,  all  of  which  were  in  private  practice,  although 
not  always  with  the  best  hygienic  surroundings  or  experienced  nursing,  I 
had  not  a  single  instance  of  failure.  There  were  two  cases  of  ischio-rectal 
abscess  and  several  of  sHght  gaping  of  the  cutaneous  wound,  but  in  every 
instance  the  perineal  body  was  solid,  the  posterior  commissure  perfect, 
and  the  object  of  the  operation  attained.  Of  these  sixty-five  cases  fourteen 
were  complete  lacerations,  and  of  these  latter  only  twice  did  the  sphincter 
ani  fail  to  unite  comj)letely,  and  then  a  few  cauterizations  produced  perfect 
control.  In  my  last  fifty  operations,  however,  I  have  not  been  so  fortunate, 
for  I  have  had  one  partial  (the  prune-stone  case)  and  four  total  failures  in 
deej)  complete  lacerations,  all  in  the  hospital ;  and  one  private  case,  where 
an  ischio-rectal  abscess  burst  into  vagina  and  rectum,  causing  a  fistula, 
which  healed  completely  in  a  few  weeks.  Of  the  partial  operations  all  suc- 
ceeded. I  have  no  explanation  to  offer  for  the  four  failures,  except  to  re- 
peat that  they  were  all  hospital  cases,  and  to  say  that,  in  one  instance,  the 
general  anemia  of  the  patient  was  certainly  to  blame.  The  cases  were 
all  very  bad  rents,  and  in  three  of  them  I  employed  the  separate  recto- 
vaginal suture  with  as  gTeat  care  as  I  could  observe.  And  still  suppura- 
tion took  place,  and  destroyed  whatever  union  had  already  occurred. 

Operation  for  Kectocele  (Posterior  Colporrhaphy). 

In  describing  the  pathological  results  of  laceration  of  the  perineum,  I 
have  already  mentioned  subinvolution  and  prolapse  of  the  posterior  vaginal 
wall,  with  or  without  the  anterior  wall  of  the  rectum — so-called  rectocele— 
as  one  of  these,  and  as  one  of  the  indications  for  perineorrhaphy.  I  there 
stated  how  rectocele  developed,  what  influence  it  has  on  the  position  of  the 
uterus,  and  how  it  was  more  or  less  relieved  by  restoring  the  perineum 
and  narrowing  the  vaginal  orifice.  By  referring  to  the  details  of  that  oper- 
ation and  examining  the  diagrams,  it  will  be  seen  that  I  have  included  a 
moderate  degree  of  rectocele  in  the  description  of  the  operation  when  it  has 


• 


Fig.  2S7.— Section  View  of  Large  Rectocele  (P.  F.  M.). 


OPERATION  FOR  RECTOCELE   (POSTERIOR  COLPORRHAPIIy).       513 

to  be  performed  for  partial  lacerations  of  the  third  degree.  Indeed,  recto- 
cele may  be  said  to  be  so  frequent  a  companion  of  the  deeper  partial  lacera- 
tions, that  the  denudation  usually  has  to  be  extended  some  distance  up  the 
vagina  to  include  the  protruding 
posterior  vaginal  wall,  in  order  to 
get  a  solid  perineum.  It  is  only 
in  the  minor  degrees  of  laceration, 
and  in  exceptional  cases  with  the 
major  rents,  that  a  rectocele  does 
not  exist ;  and  even  in  the  minor 
ruptures,  the  great  source  of  an- 
noyance and  the  indication  for 
perineorrhaphy,  is  the  redundant 
posterior  vaginal  wall.  The  oper- 
ation of  perineorrhaphy,  there- 
fore, in  the  majority  of  cases,  is 
properly  a  colpo-perineorrhaphy, 
and  that  is  the  operation  which  I 
have  chiefly  described  in  the  pre- 
ceding section. 

But  there  are  cases,  and  not 
very  uncommon  ones,  where  the 
rectocele  forms  by  far  the  most 
prominent  feature  of  the  case,  and  where  the  perineum  is  repau-ed  merely 
to  afford  a  base  of  support  to  the  constricted  posterior  vaginal  wall. 
These  are  the  typical  cases  of  rectocele  for  which  I  wish  now  to  describe 

an  operative  cure. 


Such  a  rectocele  is  depicted  in 
Fig.  287,  and  Figs.  288  and  289 
show  how  much  of  the  protiiision 
must  be  reduced  by  vivification 
and  sutures  before  restoring  the 
perineum.  With  these  large  rec- 
toceles  it  does  not  suffice  to  merely 
extend  the  denudation  upward  a 
short  distance  from  the  perineal 
wound,  as  I  have  described  under 
the  name  of  colpo-perineorrhaphy, 
but  we  must  first  constrict  the  va- 
gina so  far  as  its  posterior  wall  is 
redundant  —  that  is,  do  colpor- 
rhaphy  thoroughly,  and  then  re- 
store the  perineum,  both  of  which 
operations  are  distinct,  although 
done  at  the  same  sitting. 
Perhaps  the  most  effectual  method  for  constricting  the  vagina  is  that 
known  as  posterior  coljjorrhaphi/,  introduced  by  the  late  Professor  Simon,  of 
33 


Fig.  288.— Section  View  of  Larg:e  Rectocele,  with 
Dotted  Line  showing  Limit  of  Denudation  and  Con- 
striction of  Posterior  Vaginal  Wall  (P.  F.  M.). 


514 


GYNECOLOGICAL    OPEEATIONS. 


Heidelberg.     The  outline  of  the  denudation  on  the  posterior  vaginal  wall, 
and  its  extension  to  the  labia  and  perineum,  is  shown  in  Fig.  289.    The 


Fig.  289.— Outline  of  Denudation  for  Eeo- 
tocele  and  Perineum,  Shown  in  Section  in 
Fig.  287  (Modified  Simon's  Posterior  Colpor- 
rhapliy).    a  a,  labial  denudation  (P.  F.  M.). 


Fig.  290. — Denudation  on  Po.=!terior  Vaginal 
Wall  in  Fig.  289  Closed,  leaving  only  Super- 
ficial Perineal  Wound  (P.  P.  M.). 


patient  is  placed  in  the  gluteo-dorsal  position,  and  the  gaping  vagina  is 
exposed  by  a  fenestrated  speculum  shown  in  Fig.  293,  which  is  held  by 
an  assistant.     The  object  of  this  speculum  is  not  so  much  to  expose  the 


Fig.  291.— TJBual  Form  of  Butterfly  De- 
nudation for  Colpo-perineorrhaphy.  Dotted 
lines  indicate  that  point  r  is  drawn  down, 
to  resemble  Fig.  292.  r,  rectocele ;  1 1,  labia ; 
p,  perineum  (P.  F.  M.). 


Fig.  292. — Denudation  for  Large  Bectocele,  according 
to  Freund.  a  a,  b  b,  c  c,  dd,  points  approximated  by  su- 
tures ;  r,  apex  of  rectocele  to  be  united  to  raphe  of  peri- 
neum (P.  F.  M.). 


posterior  vaginal  wall,  which  could  easily  be  done  by  simply  everting  it 
from  the  rectum  or  drawing  it  down  with  tenacula,  but  chiefly  to  enable 


OPERATION  FOE  EECTOCELE  (POSTERIOR  COLPORRHAPHY).       515 

the  operator  with  a  bistoury  to  trace  out  the  outhue  of  the  space  to  be 
denuded  and  secure  a  symmetrical  figure.  If  the  denuded  space  is  asym- 
metrical the  line  of  union  will  not  come  in  the  middle,  and  will  not  there- 
fore be  in  the  position  where  the  greatest  support  is  needed. 

When  the  two  lateral  borders  of  the  denudation  have  been  traced  and 
joined  above  by  a  transverse  hne,  the  speculum  is  withdrawn,  and  the  oper- 
ator begins  in  the  usual  manner,  with  tissue-forceps  and  scissors,  to  denude 
the  enclosed  space  on  the  posterior  vaginal  wall,  starting  at  the  left  side 
of  the  vulva  and  proceeding  strip  by  strip,  precisely  as  in  colpo-perineor- 
rhaphy.  (Simon  used  the  knife,  and  denuded  through  the  fenestrated  specu- 
lum, but  I  prefer  the  scissors.)  As  the  denudation  advances  upward, 
the  operator  draws  the  loose  vaginal  wall  toward  him  with  the  forceps  or 
tenaculum,  or  the  field  of  denudation  may  be  exposed  by  separating  the 
lateral  walls  of  the  vagina  by  retractors,  or  Ufting  up  the  anterior  wall  with 
a  Sims  speculum.  The  length  of  the  denudation  from  the  vulva  to  its  upper 
limit  will  vary  between  three  and  five  inches,  according  to  the  size  of  the 
rectocele,  and  can  be  extended  upward  beyond  the  traced  cross  hne  if  the 


Fig.  293.— Simon's  Fenei?tratecl  Specnlum  for  Posterior  Colporrhaphy. 

operator  thinks  best.  When  a  point  not  less  than  one  inch  below  the 
cervix  is  reached,  the  operator  marks  a  point  in  the  median  line  about  one- 
half  inch  above  the  cross  line,  and  drawing  a  line  on  each  side  to  meet  the 
lateral  border  of  the  denudation,  vivifies  this  triangle.  The  object  of 
pointing  off  the  denuded  space  is  to  secure  smoother  coaptation,  and  to 
avoid  a  pucker  or  pocket  at  the  upper  limit  of  the  median  suture. 

Having  now  completed  the  posterior  denudation,  the  operator  may  at 
once  vivify  the  edges  of  the  vulva  and  the  perineum,  connecting  it  Avith 
the  vaginal  wound,  or  what  is  rather  better,  he  inserts  the  vaginal  sutures, 
ties  them,  and  then  pares  the  perineum.  He  can  then  judge  better  how 
large  a  wound  is  required  to  build  a  solid  cutaneo-muscular  foundation  for 
the  constricted  vaginal  wall.  The  sutures  for  the  vagiua  may  be  either 
wire,  silk,  or  catgut.  Simon  always  used  silk,  allowing  them  to  cut  out ; 
I  have  employed  both  wire  and  catgut,  and  certainly  prefer  wire  but  for 
the  trouble  of  removing  the  stitches  even  weeks  after  the  operation.  It  is 
difficult  to  see  and  cut  them  high  on  the  posterior  wall,  for  they  have  to 
be  removed  in  the  dorsal  position,  the  anterior  wall  being  lifted  with  a  Sims 
speculum.  Of  late  I  have  used  No.  2  catgut  entu-ely,  droppmg  the  stitches, 
and  have  been  well  satisfied.  The  sutures  are  introduced  from  above 
downward,  being  knotted  and  cut  short  as  soon  as  passed.     An  ordinaiy 


516  •  GYNECOLOGICAL    OPERATIONS. 

sui'o-ical  needle  is  used,  and  the  sutures  are  passed  underneatli  the  raw 
surface  as  carefully  as  practicable.  Here,  as  in  every  plastic  operation  in- 
volvino-  large  raw  surfaces  and  loose,  elastic  tissues,  the  formation  of 
pockets  and  grooves  should  be  avoided.  The  sutures  should  be  placed 
pretty  close  together  so  as  to  insure  perfect  coaptation  of  the  mucous 
membrane.  When  the  last  suture  has  been  tied  and  cut  short,  the  peri- 
neum is  pared  and  sutured  in  the  usual  way,  wire  being  the  best  suture, 
but  the  stitches  not  being  passed  so  deeply  as  in  simple  perineorrhaphy. 
It  is  well  not  to  bring  the  vaginal  suture  down  too  near  the  perineum,  but 
to  leave  sufficient  raw  surface  at  the  posterior  commissure  for  the  upper 
perineal  sutures,  as  in  the  ordinary  operation.  My  success  with  this 
operation,  which  I  have  performed  in  numerous  instances,  has  been  so  good 
that  I  have  not  felt  disposed  to  discard  it  for  another.  In  no  case  which  I 
have  had  occasion  to  see  again,  has  the  posterior  vaginal  wall  protruded. 
What  the  influence  of  parturition  might  be  on  the  linear  cicatrix,  I  cannot 
say,  for  none  of  my  cases  have  presented  themselves  after  that  event.  Of 
course  I  should  fear  a  stretching  of  the  cicatrix,  to  say  the  least,  and  then 
probably  a  return  of  the  rectocele. 

The  median  situation  of  the  cicatrix,  and  the  fact  that  in  the  normal 
condition  the  posterior  vaginal  wall  does  not  show  a  furrow  but  decidedly 
a  fold,  the  columna  rugarum  posterior,  with  two  lateral  furrows,  induced 
Professor  Freund,  of  Strassburg,  to  propose  a  different  operation  for  pos- 
terior colporrhaphy,  which  is  represented  in  Fig.  292.  Emmet  has  re- 
cently described  a  (as  I  understand  his  paper  before  the  American  Gjne- 
cological  Society,  in  1883)  similar  operation.  Freund  denudes  a  space 
similar  to  that  represented  in  Fig.  292  (I  have  modified  Freund's  sketch  by 
omitting  the  rectal  fissure  and  slightly  rounding  off  the  lateral  borders), 
leaving  a  central  tongue  or  flap  of  the  posterior  ruga  of  the  vagina,  and 
then  unites  the  lateral  borders  of  that  flap  to  the  mucous  membrane  of  the 
lateral  vaginal  wall  on  each  side,  thus  a  and  a,  b  and  b  on  the  left,  and  c 
and  c,  and  d  and  d  on  the  right  side,  are  united  by  as  many  sutures  as  are 
required.     When  this  has  been  done,  the  perineum  is  closed  as  usual. 

I  have  done  this  operation  once  in  the  following  way  :  In  a  large,  ex- 
ceedingly flabby  rectocele,  I  denuded  in  the  usual  manner,  extending  the 
upper  central  limit  of  the  denudation  to  a  point  fully  four  Inches  from 
the  vulva  (Fig.  291).  Then  seizing  the  centre  of  the  undenuded  mucous 
membrane  at  r  with  a  tenaculum,  I  drew  it  down  until  it  was  on  a  level 
with  the  vulva,  and  had  it  held  there  by  an  assistant.  This  was  easily 
feasible  in  the  relaxed  redundant  state  of  the  posterior  vaginal  wall,  with- 
out in  the  least  dislocating  the  uterus  ;  indeed,  the  remainder  of  the  pos- 
terior vaginal  wall  was  thereby  merely  gently  straightened.  The  denuda- 
tion then  assumed  the  shape  of  Fig.  292,  and  the  lateral  borders  of  the 
tongue  of  normal  mucous  membrane  thus  formed  were  united  by  catgut 
sutures  to  the  corresponding  borders  of  the  vaginal  and  labial  denudation 
on  each  side,  precisely  as  shown  in  Fig.  292.  The  perineum  was  then  closed 
as  usual  with  silver  sutures,  and  when  the  latter  were  removed  on  the 
fourteenth  day,  perfect  union  was  found,  which  has  proved  permanent,     I 


OPEEATION  FOR  CYSTOCELE   (ANTERIOR  COLPORRIIAPIIy).       517 

have  not  yet  formed  an  opinion  as  to  which  of  these  two  methods  is  pre- 
ferable, but  think  that  my  larger  experience  with  median  posterior  col- 
porrhaphy  would  lead  me  to  expect  greater  support  from  it  for  the  posterior 
vaginal  wall  and  the  utems.  The  Freund-Emmet  method  certainly  will 
not  answer  when  the  rectocele  is  accompanied  by  descensus  uteri,  for  the 
dragging  down  of  the  rectocele  to  form  the  central  flap  or  tongue  M'ould 
then  still  more  dislocate  the  uterus  and  fix  it  in  that  position.  Therefore 
I  am  inclined  to  believe  that  for  rectocele  and  descensus  uteri  Simon's 
method  is  the  best ;  and  for  simple  rectocele,  that  is  subinvolution  and 
redundancy  of  the  posterior  vaginal  wall,  the  Freund-Emmet  method 
seems  most  applicable. 


Operation  for  Cystocele  (Anterior  Colporrhaphy). 

The  definition  and  etiology  of  the  condition  somewhat  incoi-rectly 
termed  "  cystocele  "  have  already  been  given  when  discussing  the  patho- 
logical conditions  following  laceration  of  the  perineum.  As  "  rectocele  " 
is  not  always  a  jDrotrusion  of  the  rectum,  but  frequently  a  redundancy  or 
prolapsus  of  the  posterior  vaginal 
wall  into  which  gradually  the  an- 
terior wall  of  the  rectum  may  be 
drawn  —  so  "  cystocele  "  is  not 
properly  a  prolapse  of  the  bladder, 
except  in  so  far  as  the  base  of  that 
viscus  participates  in  the  prolapse 
of  the  anterior  wall  of  the  vagina. 
These  two  conditions  ought  prop- 
erly to  be  called  posterior  and  an- 
terior colpocele,  with  or  without 
accompanying  rectocele  and  cys- 
tocele, as  the  case  may  be.  I 
make  this  explanation  merely  to 
guard  myself  against  the  criticism 
of  giving  an  incorrect  name  to  a 
certain  condition  and  to  insure 
the  student  against  misunder- 
standing. 

A  condition  which  is  very 
readily  mistaken  for  cystocele  is  a  redundancy  of  the  anterior  vaginal 
wall  and  the  bulb  of  the  urethra  ;  I  have  seen  this  mass  so  large  as  to  pro- 
ject from  the  vulva  and  inconvenience  the  patient.  Another  condition 
liable  to  be  mistaken  for  cystocele  is  a  sacculation  of  the  urethra  alone. 

Diagnosis. — In  cystocele  the  point  of  a  sound  or  catheter  introduced 
into  the  urethra  passes  almost  directly  down  to  the  bottom  of  the  sac  pro- 
truding between  the  labia  and  can  be  felt  there  ;  in  simple  redundancy  or 
isolated  prolapse  of  the  anterior  vaginal  wall,  the  sound  goes  straight  into 
the  bladder,  and  not  down  into  the  sac  ;  and  in  urethi'ocele  the  sound  first 


Fig.  29-1. 


-Section  View  of  Cystocele.     B,  bladder ; 
vagina  ;  C,  cystocele  (V.  F.  M.). 


518 


GYNECOLOGICAL    OPERATIOiSrS. 


Fio.  295.— Rednnriancy  of  Anterior  Vaginal  Wall  sim- 
ulating Cj'stocele.  Dotted  line  shows  redundant  portion 
(P.  F.  M.). 


goes  to  the  bottom  of  the  sac,  and  then  on  being  partly  withdrawn  passes 
inward  to  the  bladder.     All   these  conditions  may  exist  together.     The 

perineum  in  vaginal  redundancy 
and  urethrocele  may  be  perfect. 
The  indications  for  anterior 
colporrhaphy  consist  not  only  in 
the  annoyance  which  the  pres- 
ence of  an  ovoid  protrusion  be- 
tween the  labia  gives  the  patient, 
but  in  the  distress  which  the 
sacculation  and  decomposition  of 
residual  urine  in  the  dependent 
bladder-diverticle  causes,  and 
finally  in  the  influence  exerted 
on  the  position  of  the  uterus. 

Not  every  case  of  cystocele 
calls  for  an  operation.  Indeed, 
while  rectocele  is  usually  incur- 
able otherwise  than  by  surgical 
means,  and  offers  the  best  pos- 
sible chances  for  permanent  cure 
thereby,  a  cystocele  justifies  an 
operation  only  when  its  symp- 
toms cannot  be  relieved  by  mechanical  supports,  or  the  condition  of  the 
part  offers  fair  inducements  that  the  relief  obtained  will  be  permanent. 
Whenever  a  cystocele  can  be  sup- 
ported with  comfort  and  with  no 
more  inconvenience  than  an  oc- 
casional removal  of  the  pessary, 
and  perhaps  its  substitution  for 
a  week  or  two  by  astringent  tam- 
pons until  a  possible  erosion  has 
been  healed,  then  by  aU  means 
be  satisfied.  In  this  way  I  have 
a  number  of  patients  wearing  a 
Gebrung  pessary  with  perfect 
comfort  for  several  years,  who 
never  would  have  been  perma- 
nently benefited  by  surgical 
means.  Such  cases  are  those  of 
minor  degrees  of  cystocele,  where 
the  tissues  are  still  possessed  of 
sufficient  tone  to  justify  the  ex- 
pectation of  a  cure  if  the  r)rO-  _,FiG- 296.— Urethrocele.  B,  bladder:  U.  urethrocele. 
lr.,^^^,1  i   •  n  ,     ,       ?^®^'"^^    ^^^"^^    ^'I'^i'®    the    fistula    should    be    made 

lapsed  part  is  i^roperly  supported     (P-  ^-  »^-)- 

for  a  year  or  two,  as  in  young  women,  whose  vaginse  have  not  yet  become 

overdistended  throughout ;  further,  old  women,  past  the  menopause,  whose 


OPERATIOIS'  FOR  CTSTOCELE   (ANTERIOR  COLPORRIIAPIIy).       519 

tissues  have  become  so  relaxed  and  flabby  from  age  and  childljearing, 
■whose  vaginal  walls  have  lost  all  contractility,  that  a  cicatrix  would  be  sure 
to  stretch  almost  as  soon  as  the  patient  leaves  her  bed.  In  such  patientw 
the  operation  is  not  justifiable,  because  it  is  either  not  necessary,  or  be- 
cause it  offers  no  prospect  of  a  cure.  But  in  cases  where  the  cystooele  is 
too  large  to  be  cured  by  a  supporter,  where  the  tissues  still  have  fair  tone, 
where  the  woman  objects  to  wearing  a  support,  and  where  there  exists  a 
rectocele  with  or  without  prolapsus  uteri  for  which  the  operations  already 
described  are  to  be  performed,  there  anterior  colpoiThaphy  is  indicated 
and  will  ordinarily  give  a  good  result. 

Operation. — The  object  is  so  to  narrow  the  anterior  vaginal  wall  that  it 
will  give  permanent  support  to  the  bladder  and  prevent  the  steady  press^ 

•u 


Fig.  297.— Oval  Denudation  for  Cystocele. 
TJ,  urethra  ;  C,  cervix  (P.  F.  M.)- 


Fig.  298. — Horseshoe  Denudation  for  Cysto- 
cele. U,  urethra:  C,  cervix  (P.  F.  M.). 


ure  of  that  organ  from  again  forcing  it  down  into  the  vagina.  To  secure 
this  object  various  methods  have  been  devised,  most  of  which  are  open  to 
the  same  objection,  of  failing  to  furnish  a  cicatrix  which  will  not  stretch 
in  time  and  allow  the  old  prolapse  to  return.  The  open  horseshoe  of 
Sims  and  closed  horseshoe  of  Emmet,  the  oval  denudation  of  Dieffenbach 
and  numerous  others,  down  to  the  present  day,  all  are  open  to  this  same 
objection,  and  the  ideal  operation  for  .cystocele  has  still  to  be  invented. 
Another  objection  to  these  horseshoe  and  oval,  in  fact  to  all  shapes  of 
longitudinal  denudations,  is  that  the  number  of  sutures  required  to  close 
them  is  so  large  as  to  make  their  eventual  removal,  if  silver,  a  somewhat 
arduous  task— a  point  of  considerable  importance  in  the  numerous  cases 
where  cystocele  is  contemporaneous  with  rectocele  and  laceration  of  the 
perineum,  and  where  it  is  desirable  to  perform  these  operations,  if  possi- 
ble, at  the  same  sitting.     Of  course,  catgut  and  silk  might  be  used,  but  the 


520 


GYNECOLOGICAL    OPERATIOlSrS. 


former  is  so  soon  absorbed  as  to  be  scarcely  reliable  for  cystocele,  and  silk 
must  either  be  allowed  to  cut  out  or  remain  for  at  least  three  weeks. 

It  may  as  well  be  laid  down  as  a  fundamental  principle  for  anterior 
colporrhaphy,  even  more  than  for  denudations  on  the  posterior  wall,  that 
the  larger  the  denuded  surface  the  firmer  the  cicatrix  and  the  more  per- 
manent the  result ;  and  that  all  methods  which  allow  undenuded  vaginal 
mucous  membrane  to  be  enclosed  by  linear  cicatrices  are  to  be  condemned. 

The  denudation  may  be  accomplished  in  two  ways :  1,  by  clasping  a 
longitudinal  fold  of  vaginal  mucous  membrane  in  a  clamp  (a  method 
which,  by  the  way,  has  been  employed  in  rectocele,  but  is  now  abandoned), 
passing  the  sutures  underneath  the  clamp,  slicing  off  the  fold  close  above 
the  clamp,  and  then  tying  the  sutures ;  and  2,  by  tracing  out  the  space  to 

IX. 


Fig.  209.— Emmet's  Operation  for  Cystocele. 
First  step,    u,  urethra  (Emmet). 


Fig.  .SOO.— Emmet's  Operation  for 
Cystocele.  Second  step,  after  twisting 
sutures  shown  in  Fig.  299.  u,  urethra ; 
c,  cervix  (Emmet). 


be  denuded  with  tissue-forceps  and  scissors,  and  then  paring  oif  strip 
after  strip  with  the  scissors,  as  in  perineorrhaphy  ;  then  introducing  the 
sutures  completely  under  the  raw  surface  and  tying  or  twisting  them, 
and  cutting  the  ends  short.  In  either  method  the  bladder  should  be  lifted 
away  by  a  thick  sound  in  its  cavity,  and  with  any  fair  care  it  cannot  well 
be  injured. 

^  The  denudation  should  extend  from  slightly  below  the  meatus  to 
within  a  half  to  one  inch  of  the  cervix.  A  reference  to  the  diagrams  (Figs. 
297  and  298)  will  illustrate  the  principles  of  the  ovoid  and  horseshoe 
denudations.  Figs.  299  and  300  show  a  recent  method  devised  by  Em- 
met. In  Fig.  299  is  represented  the  first  step  of  the  operation,  the  vivifi- 
cation  of  three  oval  surfaces  just  below  and  to  either  side  of  the  cervix, 
which  are  brought  together  by  a  wire  suture,  which  is  twistnd.  In  this 
manner  two  longitudinal  folds  are  produced  on  the  anterior  wall  reaching 
almost  to  the  meatus.  The  edges  of  these  folds  are  vivified  from  the  cer- 
vix forward,  and  as  each  half-inch  of  denudation  is  accomplished,  the  sut- 


OPEKATIOlSr  FOR  CYSTOCELE  (ANTERIOR  COLPORRHAPHy).       521 


ures  are  passed  and  twisted,  thus  avoiding  loss  of  blood,  until  tlie  end  of 
the  folds  is  reached.  The  objection  to  this  method,  in  my  opinion,  is  the 
small  amount  of  denuded  tissue,  which  objection  might  be  obviated  by 
paring  all  the  intervening  tissue  between  the  two  longitudinal  folds  before 
twisting  the  first  suture. 

V 


0 


Fig.  SOI. — Emmefs  Operation  for  TTrethrocele 
and  Cystocele.  First  step.  A,  B,  D,  E,  points 
joined  by  sutures ;  U,urethra ;  C,  cervix  (Emmet). 


Fig.  302.— Emmet's  Operation  for 
Urethrocele  and  Cystocele.  Second 
step.  Sutures  twisted.  U,  urethra  ; 
C,  cervix  (Emmet). 


For  cystocele  with  urethrocele,  or  with  an  excess  of  tissue  about  the 
bulb  of  the  urethra,  Emmet  has  devised  an  operation  consisting  of  a  pecul- 
iar hoof-like  denudation,  extending  from  cervix  to  bulb  of  urethra,  and 
then  spreading  along  each  side  of  the  urethra,  and  meeting  by  a  concave 


Fig.  303.— Emmet's  Operation  for  Urethrocele,  Side  View  (Emmet). 

line  in  the  centre  (Fig.  301).     Why  the  centre  of  this  figure  is  not  also 
denuded,  I  do  not  comprehend. 

The  longitudinal  denudations  have,  in  my  hands,  failed  to  secui'e  per- 


522 


GYNECOLOGICAL    OPERATIONS. 


manent  relief,  for  the  very  reason  mentioned,  the  early  stretching  of  the 
cicatrix.  And  in  the  very  cases  where  I  hoped  for  the  most  benefit  from 
the  cystocele  operation— that  is,  when  I  wished  to  restore  at  the  same  sit- 
ting the  natiu-al  support  of  the  anteiior  vaginal  waU,  the  perineum,  the 


Fig.  304,— Stoltz's  Operation  for  Cystocele. 


c 

Fir.st  step.    U,  nrethra ; 


C,  cervis  (P.  F.  M.). 


Af- 


leno-th  of  time  required  to  denude  and  introduce  the  numerous  sutures, 
and  the  subsequent  difficulty  of  removing  them,  dissuaded  me  from  at- 
tempting these  methods.  Hence,  when,  a  few  years  ago,  a  new  method, 
devised  by  Stoltz,  of  Nancy,  became  known  to  me,  which  seemed  to  do 
away  with  these  objections,  I  tried  it,  and  have  since  had  considerable  ex- 
perience with  it.  It  is  represented  in  Figs.  304  and  305,  and  may  be 
called  the  tobacco-pouch  operation.  The  patient  is  placed  in  the  lithot- 
omy position  (for  the  other  operations  on  the 
anterior  vaginal  wall  she  may  be  either  on  the 
back  or  in  Sims'  position,  when  the  operation  is 
done  through  Sims'  speculum),  the  anterior  va- 
ginal wall  is  pressed  out  by  a  thick  sound  in  the 
bladder,  so  as  to  render  it  prominent  and  tense, 
and  the  opierator  proceeds  to  trace  out  with 
tissue-forceps  and  flat-curved  scissors  (perineum 
scissors)  a  circular  space,  varying  in  size  from  a 
silver  dollar  to  three  inches  in  diameter,  extend- 
ing from  about  half  an  inch  of  the  meatus  to  the 
same  distance  of  the  cervix.  This  space  he  rap- 
idly denudes  with  the  scissors,  of  course  being 
careful  to  pare  superficially  so  as  not  to  injure 
the  bladder.  Two  sHghtly  cui'\-ed,  flat,  sharp-pointed  anatomical  needles 
are  then  threaded  with  a  double  piece  of  No.  2  braided  silk,  one  needle  at 
each  end,  and,  beginning  just  in  front  of  the  cei-vix,  the  suture  is  passed 


Pro.  305.— Stoltz'B  Operation 
for  Cystocele.  Second  step.  U, 
urethra  ;  0,  cervix  (P.  F.  M.). 


OPERATION    FOR    URETHROCELE.  523 

on  one  side  of  the  raw  surface,  in  and  out  of  the  mucous  membrane,  about 
half  an  inch  from  the  edge,  until  it  reaches  the  median  line  l^etween  meatus 
and  denudation  ;  the  same  is  done  with  the  other  end  of  the  suture  on  the 
other  side,  and  the  ends  are  then  crossed,  and  the  denuded  surface,  being 
cleaned,  is  pressed  inward  toward  the  bladder  with  the  point  of  a  sound, 
and  the  suture  is  firmly  tied,  the  sound  being  removed  at  the  last  mo- 
ment. One  end  of  the  sutm-e  is  cut  short,  and  the  other  fastened  to  the 
thigh  or  inguinal  skin  by  adhesive  plaster.  To  allow  this,  the  suture 
should  be  at  least  twelve  inches  long.  A  thick  button  is  thus  formed  in 
the  bladder,  the  raw  surfaces  of  which  adhere,  and  which  gives  no  incon- 
venience whatever.  This  operation  can  easily  be  done  in  twenty  minutes, 
and  is  difficult  only  through  the  trouble  experienced  in  j^assing  the  needles 
thi'ough  the  movable  anterior  wall,  a  point  wherein  all  these  anterior  col- 
porrhaphy  operations  differ  from  those  on  the  posterior  wall.  By  pushing 
the  mucous  membrane  over  the  needle,  as  is  done  in  "  gathering  "  linen 
while  sewing,  the  passage  of  the  suture  can  be  facihtated.  The  colpo- 
perineorrhaphy,  which  usually  follows  this  cystocele  operation,  can  now  be 
proceeded  with,  and  the  whole  combined  operation  will  scarcely  exceed 
one  and  a  quarter  to  one  and  a  half  hour.  The  after-treatment  consists  in 
catheterization  every  four  hours,  or  the  permanent  sigTooid  or  velvet-eye 
catheter.  On  the  seventh  day  the  sutm-e  is  cut  by  simply  drawing  on 
the  free  end  and  exposing  the  small  loop  just  below  the  meatus  into  which 
the  suture  has  been  tied.  Of  course,  as  after  all  plastic  operations  on  the 
female  genitals,  the  longer  the  patient  remains  in  the  recumbent  j^osition, 
the  firmer  the  cicatrix  and  the  better  the  result.  I  have  been  so  weU 
pleased  with  this  operation  that  I  no  longer  perform  any  other. 

Operation  for  Urethrocele. 

As  already  stated,  this  term  designates  a  sacculation  of  the  ui-ethra 
alone  (see  Fig.  296),  and  produces  symptoms  and  requires  treatment 
peculiar  to  itself.  It  may  accompany  cystocele,  it  is  true,  but  is  then 
remediable  by  an  operation  designed  for  both  conditions. 

When  occurring  alone,  as  a  distinct  pathological  factoi',  it  produces 
very  aggravating  symptoms,  the  chief  of  which  is  painful  and  difficult  mic- 
turition. This  is  due  to  a  retention  and  decomposition  of  urine  in  the 
urethral  pouch,  to  inflammation  of  the  mucous  membrane  of  that  pouch 
and  of  the  whole  urethra,  perhaps  eventually  of  the  bladder  also,  and  ulti- 
mately to  a  purulent  discharge  from  the  m-ethra.  This  discharge  in-itates 
the  meatus  and  excites  the  growth  of  the  papillomatous  formations  known 
as  carunculse.  These  latter  cannot  be  cured  unless  the  source  of  irritation 
is  removed,  and  then  they  may  disappear  spontaneously.  I  have  tried 
over  and  over  again  to  cure  them  by  the  scissors  and  nitric  acid,  and  still 
they  returned,  until  I  performed  the  operation  which  allowed  the  pus  and 
irritating  urine  to  escape  by  another  orifice  than  the  meatus,  and  then 
they  disappeared  not  to  return. 

This  operation,  which  we  owe  to  Emmet,  consists  in  making  a  puncture 


524  GYNECOLOGICAL    OPERATIONS. 

or  button-hole  at  the  bottom  of  the  urethral  pouch,  and  substituting  this 
orifice  for  the  natural  meatus.  The  urethrocele  is  forced  out  through  the 
vulvar  cleft  by  a  grooved  sound  in  the  urethra,  and  a  slit  is  cut  in  its 
most  dependent  portion  ;  the  hyperplastic  mucous  urethral  membrane  is 
draAvn  through  this  slit  with  a  tenaculum,  trimmed  down  until  the  ure- 
thral canal  appears  free,  and  its  border  is  sewed  by  fine  silk  or  catgut 
sutui'es  to  the  mucous  membrane  of  the  vagina.  This  keejDS  the  slit  open, 
which  otherwise  would  contract  or  become' obstructed,  and  the  object  of 
the  operation  frustrated.  Emmet  has  devised  an  instrument  like  a  shoe- 
maker's punch,  by  which  he  expected  to  prevent  the  spontaneous  closure 
of  the  opening  ;  but  I  think  he  now  prefers  the  slit  and  suture  as  de- 
scribed. Of  course  the  slit  should  not  be  extended  ujjward  so  far  as  to 
involve  the  neck  of  the  bladder,  for  then  incontinence  would  result.  The 
length  of  the  incision  should  be  about  half  an  inch.  It  should  be  kept 
open,  and  the  urethra  washed  out  with  tepid  carbolized  or  acidulated 
water  for  several  weeks,  until  the  urethral  disease  is  cured.  The  patient 
has  perfect  continence  ;  she  merely  urinates  through  the  new  opening, 
instead  of  the  meatus,  and  if  she  desires,  the  opening  need  not  be  closed 
at  all.  Its  closure  is  easily  effected  by  trimming  the  edges  and  uniting 
them  by  fine  wire  sutures. 


■--/- 


V  ' 


pr!}™-7\lLnd^W^^^^  Simple  Prolapsus.    1.  normal  position  ;  9,  first  degree  of 

prolapsus,  d,  second  degree  of  prolapsus  ;  u  a,  uterine  axis;  v  a,  vaginal  axis ;  p  f,  pelvic  floor  (pfp.  m!). 

Operations  for  Prolapsus  Uteri  et  Vagina. 
The  operations  for  prolapsus  of  the  vagina  (rectocele  and  cystocele) 
have  ah-eady  been  described.     Hence  it  but  remains  to  discuss  those  forms 


OPERATIONS  FOR  PROLAPSUS  UTERI  ET  VAGINiE.     525 


Fig.  307.— Total  Prolapsus  of  Uterus  and  Vagina  (P.  P.  jr. ). 


of  prolapsus  vagina  complicated  with  descent  of  the  uterus,  in  which  the 
operative  measures  for  retaining  the  displaced  organs  difler  from  those 
practised  in  prolapse  of  the  va- 
gina alone. 

Varieties  and  Degrees. — To 
prevent  confusion  in  describing- 
and  comprehending  the  prin- 
ciple of  the  different  operative 
methods,  I  will  briefly  enumer- 
ate and  explain  the  varieties  and 
degrees  of  prolapsus  of  the  va- 
gina and  uterus. 

Prolajjsus  of  the  vagina  alone, 
rectocele  and  cystocele.  Both 
these  conditions  may  exist  to- 
gether, or  one  only  may  be  pres- 
ent. 

Descensus  uteri  alone,  ivithout 
prolapse  of  the  vagina.  Two  de- 
grees :  1.  Cervix  rests  on  pelvic 
.  floor  ;  2.  Cervix  at  vulva.  Or- 
dinarily the  books  make  three 
degrees  of  prolapsus  uteri,  but 
when  the  organ  reaches  the  third  degree — that  is,  protrudes  fi'om  the 

vulva — the  vagina  always  takes 
part  in  the  prolapsus. 

Prolapsus  or  procidentia  ute- 
ri, with  prolapse  of  one  or  both 
walls  of  the  vagina.  I  have  al- 
ready stated,  in  discussing  the 
pathological  results  of  lacera- 
tion of  the  perineum,  that  pro- 
lapsus of  the  uteiTis  and  the  va- 
gina develops  in  three  ways  :  1. 
The  vaginal  walls,  one  or  both, 
l^rolapse  first,  then  the  uterus 
gradually  descends,  becomes  an- 
teverted  first  if  the  cystocele  pre- 
dominates then,  or  at  once  ret- 
roverted,  and  finally,  with  the 
vagina,  escapes  through  the  vul- 
var cleft;  that  is,  the  uterus  is 
dragged  down  by  the  vagina. 
In  this  variety  the  uterus  may 
be  of  normal  size,  or  it  may  orig- 
inally be  or  may  become  enlarged  during  the  process  of  being  dragged 
down.     The  two  last  named  conditions  are  the  most  common.     The  cer- 


PlG.  308. — Prolapsus  of  Uterus  with  Cystocele  ouly 
(P.  F.  M.). 


526 


GYNECOLOGICAL    OPERATIONS. 


-Prolapsus  of  TTterus  with  Rectooele  only 
(P.  F.  M.). 


vix,  chiefly  the  supravaginal  portion  of  it,  becomes  elongated  or  hyper- 
plastic, and  a  uterus  of  two  and  a  half  to  three  inches  is  drawn  out  to  a 

length  of  four  to  seven  inches. 
A  curious  j^henomenon  is  then 
"witnessed,  namely,  that  in  re- 
l^lacing  the  uterus  and  vagina 
its  length  at  once  diminishes  to 
nearly  one-half — from  seven  to 
four  inches,  for  instance.  Em- 
met very  ingeniously  explains 
this  by  saying  that  the  uterine 
tissue  is  ductile,  when  prolapsed 
it  is  drawn  out  by  the  traction 
of  the  vagina,  and  when  replaced 
it  simply  retracts.  He  calls  it 
the  "putty-like"  condition.  2. 
The  uterus  is  subinvoluted, 
heavy  ;  its  hgaments  are  relaxed, 
and  allow  the  heavy  organ  to 
sag  down  into  the  pelvis,  and 
gradually  along  the  axis  of  the 
pelvic  outlet  until  it  emerges 
through  the  vulva,  all  this  time 
dragging  the  vagina  after  it  as  it  descends.  Here  we  have  the  vagina 
drawn  down  by  the  uterus,  and  either  both  walls  may  be  prolapsed,  or 
only  one.  Thus  we  will  find  the 
cer\-ix  with  the  anterior  vaginal 
wall  protruding  two  inches  be- 
yond the  vulva,  and  the  poste- 
rior vaginal  wall  nearly  in  its 
normal  j^osition,  admitting  the 
finger  two  inches  or  more  to 
the  fornix  vaginae  ;  or,  what  is 
less  common,  there  is  only  a  rec- 
tocele,  and  the  anterior  vaginal 
pouch  is  preserved.  (See  Figs. 
308  and  309.)  3.  Both  these 
conditions,  pi'olapse  of  the  va- 
gina and  heavy  uterus,  may  be 
present  and  active  fi'om  the 
very  outset,  and  the  uterus  be 
both  dragged  down  and  sag- 
ging by  its  weight  at  the  same 
time.     And   I   dare  say  a  large 

proportion     of     cases    of     prolar)-  ^^'^-  310.— Hypertrophic   Elongation  of   Supravaginal 

^  ^        Portion  of  Cervix  with  Downward  Growth  of  Vagina  sim- 

SUS  ai'e  developed   by  both  these     "lating  True  Prolapsus  (P.  F.  JI.). 

two  factors  of  vis  a  f route,  dragging,  and  vis  a  tergo,  forcing. 


OPERATIONS    FOP.   PROLAPSUS    L'TERI    ET   YAGIN^.  527 


A  retroverted  uterus  may  occasionally  be  the  means  of  detaching  the 
vagina  and  gradually  forcing  it  downward,  until  uterus  and  vagina  are  out- 
side of  the  body.  In  such  a  case  the  uterus  is  the  primary  factor,  al- 
though the  inverted  vagina  apjDears  at  the  orifice  first.  This  occurrence  is 
possible  only  where  the  vaginal  attachments  are  exceedingly  lax,  as  is  the 
case  soon  after  delivery,  and  in  flabby,  debilitated  multiparte. 

When  a  prolapsus  has  existed  for  some  time  the  vaginal  walls  are  gen- 
erally greatly  hypertrophied  and,  as  well  as  the  cervix,  more  or  less  ede- 
matous. 

Very  commonly  the  cervdx  is  lacerated,  the  same  parturient  factors 
•which  overdistended  the  vaginal  walls  and  i-uptured  the  perinevun  having 
also  torn  the  cervix,  which  be- 
comes everted  and  enormously 
hypertrophied.  The  everted 
lips  gradually  become  blend- 
ed with  the  prolapsed  vagina 
through  traction,  and  the  cervi- 
cal canal  is  widely  patulous. 

Hyjpertrophic  Elongation  of 
the  Cervix  ivith  Apparent  Pro- 
lapse of  the  Vagina  Simulating 
True  Prolajjsus. — There  is  a  very 
common  pathological  condition 
"which  has  often  been  mistaken 
for  prolapsus,  and  has  been  de- 
scribed and  treated  as  such  by 
Huguier,  Braun  and  others,  who 
called  it  "  prolapsus  uteri  with- 
out descent  of  the  fundus," 
which  is  no  prolapse  at  all,  but 
nothing  else  than  a  hypertro- 
phic elongation  of  the  suj)ra- 
vaginal  portion  of  the  cervix,  in  consequence  of  which  the  vaginal  walls, 
being  pretty  firmly  attached  to  the  cervix,  are  earned  down,  grow  down,  in 
fact,  with  that  organ  ;  the  external  os  protrudes  from  the  vulva  more  or  less, 
and  is  on  a  level  with  the  vaginal  wall.  The  resemblance  to  true  prolapsus 
is  perfect.  But  the  difference  is  easily  recognized  by  bimanual  exami- 
nation, when  the  fundus  uteri  will  be  found  in  its  normal  position  above 
the  symphysis ;  and  by  endeavoring  to  replace  the  uterus,  which  either 
will  not  succeed,  or  if  it  apparently  succeeds  by  flexing  the  uterus,  the 
sound  will  show  the  length  of  its  cavity  undiminished  instead  of  reduced 
nearly  one-half,  as  in  the  ductile  uterus  of  tme  prolapsus.  Besides,  a  pai'- 
ticipation  of  bladder  and  rectum  in  the  prolapse  of  their  respective  vaginal 
walls  is  less  common  in  this  pseudo-prolapsus  than  in  the  true  variety.  I 
am  aware  that  there  is  a  difference  of  opinion  as  to  the  manner  in  which 
the  vaginal  walls  participate  in  the  cervical  hypertrophy  ;  but  the  process  I 
have  described  seems  to  me  the  most  natui-id  and  plausible  explanation. 


Fig.  311 . — Hypertrophic  Elongation  of  Cervix  only,  simu- 
lating Prolapsus  Uteri  (P.  P.  M.). 


528  GYISTECOLOGICAL    OPERATIONS. 

The  importance  of  recognizing  this  spui'ious  variety  is  very  evident  when- 
it  comes  to  treatment,  both  by  supporters  and  the  knife,  for  j)essaries  are 
of  no  use  because  there  is  no  room  for  them  in  the  vagina,  and  the  cervix 
needs  to  be  shortened  by  amputation  to  effect  a  cure  of  the  apparent  pro- 
lapsus (Fig.  310). 

Simple  Hypertrophic  Elongoiioyi  of  the  Intravaginal  Portion  of  the  Cervix 
Simulating  Prolapsus  Uteri. — Here  only  that  portion  of  the  cei-vix  hyper- 
trophies which  is  in  the  vagina,  the  fornix  remaining  stationary.  A  digital 
examination  easily  reveals  the  true  nature  of  the  case.  Emmet  denies 
the  existence  of  this  malformation,  but  other  observers  insist  upon  its  oc- 
currence. 

While  as  a  rule  a  uterus,  in  order  to  be  able  to  escape  through  the 
vulvar  cleft,  must  first  be  retroverted  and  its  longitudinal  axis  be  in  a 
line  with  the  axis  of  the  vagina,  cases  do  occur  where  an  originally  ante- 
flexed,  not  enlarged  uterus,  is  earned  bodily  through  the  vaginal  orifice 
by  the  descent  of  the  vaginal  walls,  and  the  same  may  haj)pen  with  a  small 
retroflexed  uterus,  the  whole  organ,  fundus  and  all,  being  outside  of  the 
body.  The  complete  prolapse  of  the  whole  uterus,  so  that  the  fundus  is 
outside  of  the  vulva,  is  rarely  met  with  except  when  the  uterus  is  not  en- 
larged (Fig.  311). 

Symptoms  and  Significance. — It  is  hardly  necessary  to  expatiate  at 
length  on  the  inconvenience  which  must  obviously  arise  to  a  woman  from 
a  prolapsed  vagina  and  uterus.  Not  only  the  presence  of  a  large  mass 
between  the  labia,  which  usually  becomes  ulcerated  and  the  seat  of  a  foul 
acrid  discharge,  but  the  dragging  on  the  pelvic  organs  (ligaments,  bladder 
and  rectum)  render  a  woman  suffering  from  complete  prolapsus  a  con- 
firmed invalid  and  an  object  of  pity.  Even  the  minor  degrees  of  displace- 
ment may  make  life  a  burden,  and  incapacitate  the  sufferer  from  pursuing 
her  vocation. 

Indications  for  Operation. — Not  every  prolapsus  justifies  an  operation. 
What  was  said  of  cystocele  in  this  respect  applies  faii'ly  well  here.  Fii'st 
of  all,  the  minor  degrees  of  descensus  uteri  are  usually  remediable,  or 
susceptible  of  temporary  relief,  by  supporters  ;  and  the  same  holds  good 
of  many  cases  of  cystocele  and  rectocele,  particularly  the  former.  What 
operative  measures  to  employ  in  extreme  cases  of  these  displacements,  and 
when  they  are  indicated,  has  akeady  been  mentioned.  And  it  will  be 
evident  that,  precisely  the  same  operative  devices  as  were  used  for  these 
vaginal  displacements  will  be  indicated  in  cases  of  prolapsus  uteri  with 
prolapse  of  the  vagina. 

As  a  general  rule,  we  may  assume  that  thi-ee  classes  of  complete  pro- 
lapse do  not  indicate  operative  treatment :  1.  When  the  displacement  is  re- 
cent, and  has  occurred  soon  after  delivery,  before  involution  has  taken 
place,  or  in  consequence  of  a  sudden  violence,  such  as  a  strain  ;  in  fact,  when 
the  tissues  are  still  capable  of  restoration  to  a  healthy  tone  by  jDroper  and 
persistent  local  treatment  and  support  (astringent  tampons,  recumbent 
position,  suitable  pessaries).  2.  When  the  patient  has  long  passed  the 
menopause   and   the    tissues    have   acquired  the  relaxed,   ah-oiDhic   state 


OPERATIONS  FOR  PROLAPSUS  UTEPJ  ET  VAGIX.E.     529 

peculiar  to  old  age ;  here  an  operation  would  be  but  temporarily  suc- 
cessful, for  the  cicatricial  constrictions  of  the  vagina  and  perineum  would 
soon  stretch,  and  the  prolapse  return  before  the  patient  has  had  time  to 
imagine  herself  cured.  3.  When  the  displacement  is  such  that  a  safe  and 
simple  supporter  will  retain  the  prolapsed  organs  in  position,  with  com- 
paratively slight  discomfort  to  the  patient,  as  is  done  by  a  Gehrung  pessary 
in  many  instances  (see  page  387),  and  occasionally  by  a  large  hard  or 
soft  ring,  or  a  cup  and  stem  supporter.  These  cases  will  be  found  chiefly 
in  women  who  either  will  not  submit  to  an  operation,  or  in  whom  the  ai> 
proach  of  the  menopause  renders  palliative  measui-es  more  ad\dsable  than 
radical  treatment. 

An  additional  counter-indication  against  operative  treatment  for  pro- 
lapsus might  be  found  in  the  social  condition  of  many  of  the  sufferers  from 
this  affection.  To  operate  on  a  woman  whose  poveiiy  requires  her  to 
resume,  almost  before  the  wounds  are  firmly  healed,  the  same  occupations 
which  first  produced  the  prolapsus  (such  as  washing,  carrying  water  and 
coal  up-stairs,  in  short,  the  household  drudgery  of  the  poor  in  all  its  phases), 
seems  hardly  worth  the  while,  for  it  is  but  a  question  of  time,  short  at 
that,  until  the  displacement  returns  as  badly  as  before.  Such  women  are 
most  relieved  with  least  trouble  and  expense  by  the  daily  astringent  tam- 
pon described  on  page  208. 

The  cases  of  prolapsus  which  distinctly  call  for  oi^erative  treatment — 
that  is  for  radical  cure,  are  those  occurring  in  women  still  in  the  jDrime  of 
life,  who  do  not  wish  to  remain  invalids  for  the  remainder  of  their  Hves, 
and  who  are  able  so  to  take  care  of  themselves  after  the  operation  as  to 
give  the  Avound  time  to  become  thoroughly  healed.  The  more  the  pro- 
lapsus seems  to  dej^end  on  a  subinvoluted  uterus  with  lacerated  cervix, 
the  more  the  absence  of  the  perineum  apj)ears  to  be  chargeable  with  the 
prolapsus  of  the  vagina,  and  the  more  succulent  and  healthy  the  tissues, 
not  only  of  the  prolapsed  organs,  but  of  the  adjacent  parts  ;  the  better  the 
outlook  from  an  ojDerative  treatment  of  the  several  lesions. 

Objects  of  the  Operation. — The  object  in  view  by  an  operative  treat- 
ment of  prolapsus  uteri  et  vaginae  are  twofold  :  1,  To  reduce  the  size  of 
the  uterus,  if  it  be  enlarged,  as  it  generally  is  ;  and  2,  to  retain  the  uterus 
as  nearly  as  possible  at  its  normal  elevation  in  the  pelvic  cavity  by  con- 
stricting the  vagina  and  restoring  the  perineum,  that  is,  by  sui^plying  to 
the  uterus  its  natural  support,  the  vagina,  and  to  the  vagina  its  physiolog- 
ical pedestal,  the  perineum. 

The  first  object  can  be  achieved  either  by  palliative  local  treatment 
(scarification  or  leeches  to  the  cervix,  intra-uterine  apphcations,  astringent 
tampons,  reposition  and  recumbent  position,  hot  douches),  or  by  trache- 
lorrhaphy, if  the  cervix  is  torn,  or  by  both  ;  or  by  amputation  of  a  portion 
of  the  cervix,  if  it  chiefly  is  hypertrophic. 

The  second  object  is  secured  by  anterior  and  posterior  colporrhaphy 
(already  described),  either  one  alone,  as  the  case  may  requii'e,  or  both  to- 
gether, and  then  by  perineon-haphy. 
31 


530 


GYNECOLOGICAL    OPERATIONS. 


Operations. 

The  best  operation,  in  my  opinion,  for  prolapsus  uteri  with  cystocele 
and  rectocele  (Fig,  307),  is  a  combination  of  Stoltz's  operation  for  cystocele 
(see  Fig.  304)  and  the  naodified  Simon's  operation  for  rectocele  and  peri- 
neal laceration,  shown  in  Fig.  289.  If  the  cervix  is  lacerated,  it  should 
first  be  operated  on,  the  sutures  being  either  catgut,  silk,  or  preferably 
wii-e  ;  the  uterus  is  then  replaced,  anterior  colporrhaphy  done,  and  thirdly 
and  finally  colpo-perineorrhaphy. 

If  but  one  wall  of  the  vagina  is  prolapsed,  that  alone  need  be  con- 
stricted, but  the  perineum  will  probably  always  need  restoration. 


Fig.  312.— Amputation  by  Galvano-cautery  Loop  of  Hypertrophic  Cervix  in  Prolapsus  (real  and  appar- 
ent). The  irregular  outlines  of  vagina  and  portion  of  cervi.K  to  be  amputated  is  intended  to  show  the  de- 
tachment of  the  vagina  from  the  cervix  by  the  knife  (P.  F.  M.). 

If  the  cervix  is  very  much  enlarged,  and  even  trachelorrhaphy,  with 
ample  excision  of  redundant  tissue,  seems  insufficient,  the  cei'vix  may  be 
shortened  in  the  following  manner  :  A  circular  incision  is  made  through 
the  vaginal  mucous  membrane  about  half  an  inch  above  the  external  os, 
and  with  the  scalpel-handle  the  mucous  membrane,  including  bladder  and 
perhaps  rectum,  is  pushed  up  until  about  an  inch  of  the  cervix  is  thus  ex- 
posed ;  the  platinum  loop  of  a  galvano-cautery  battery  is  then  passed 
around  this  denuded  portion  of  the  cervix  ;  the  wire  is  slightly  sunk  by 
gently  tightening  the  screw,  and  the  cervix  is  very  slowly  seared  through 
(Fig.  312).  The  bladder  is  in  the  meanwhile  held  away  by  a  sound  in  the 
cavity.  The  uterus  is  then  replaced,  and  the  vagina  securely  tamponed.  In 
due  time  the  slough  separates,  and  the  wound  cicatrizes,  and  when  this  has 


OPERATIONS  FOR  PROLAPSUS. 


531 


taken  place  it  will  become  apparent  -whether  any  additional  nan-owing  of 
•the  vagina  is  needed,  for  the  circular  cicatricial  contraction  of  the  vaginal 
vault  may  have  attached  the  vaginal  walls  so  securely  as  to  prevent  their 


Fig.  313. — Hegar's  Denudation  for  Prolapsus.     Front  view. 

descent.  If  this  method  of  treatment  could  be  emi^loyed  in  all  cases  of 
prolapsus,  the  results  would  be  much  more  satisfactory  than  they  are ; 
but  it  is  restricted  to  those  cases  where  there  is  little  prospect  of  futiare 
parturition,  and  where  the  uterus  and  vagina  are  both  hypertrophied.  To 
produce  a  circular  cicatrixrfastening  uterus  and  vagina  firmly  in  the  pelvic 
cavity,  besides  risking  the  cicatricial  stenosis  of  the  external  os  so  liable  to 
follow  the  cautery,  would  hardly  be  justifiable  except  in  a  woman  of  ad- 


FlG.  314.— Hegar's  Denudation  for  Prolapsus. 
Front  and  side  view  (Fritsch). 


Fio.  31,5.— Fritsch's  Penudntion  for 
Prolapsus.  According  to  siJie  of  vnyrinn, 
a  d,  may  measure  three  to  four  inches 
a  b.  three  and  a  half  inches,  b  d  l>.  three 
inches  in  lenjjth  ( Fritsch ). 


vanced  years.     I  have  had  several  excellent  results,  with  no  drawbacks, 
in  women  at  or  beyond  the  climacteric  period. 

Instead  of  the  modified  Simon  operation  for  posterior  colpo-perineor- 


06 


P.  9 


GYNECOLOGICAL    OPEEATIONS. 


rliapliT,  which  together  with  Stoltz's  operation  has  done  me  very  good  ser- 
vice, there  are  several  other  foims  of  denudation  of  the  posterior  vaginal 
wall  which  are  highly  recommended  by  their  inventors,  and  I  shall  briefly 
describe  those  which  seem  to  me  to  offer  the  best  chances  for  permanent 
cure,  viz.,  the  methods  of  Hegar,  Fritsch,  Martin,  Bischoff,  Neugebauer, 
and  Lefoi*t. 

Hegar's  method  is  very  similar  to  that  of  Simon,  with  the  exception  that 
the  denudating  on  the  posterior  wall  is  rather  more  pointed  (Fig.  313  and 
314).  A  reference  to  the  diagrams  of  these  operations  will  explain  their 
designs  better  than  words.  Fritsch  objects  to  the  pointed  shape  of  Hegar's 
denudation,  and  substitutes  that  shown  in  Fig.  315,  which  I  decidedly  pre- 


FlG.  .316.— Section  View  of  Pelvic  Organs  with  Posterior  Vaginal  Wall  built  np  by  Hegar's  Operation, 
Fntsch  says  that  this  smooth  triangle  in  reality  becomes  puckered  from  above  downward  (Fritsch). 

fer  myself,  and  which  will  be  seen  to  resemble  very  closely  that  employed 
by  me  for  the  same  purjDose,  and  described  when  speaking  of  extreme  de- 
grees of  rectocele  (Fig.  289). 

The  object  of  Martin's  and  Bischoff 's  methods  is  to  save  the  normal  cen- 
tral elevation  of  the  posterior  vaginal  wall,  the  columna  rugarum  posterior, 
and  to  form  two  natural  lateral  fuiTOws.  In  Martin's  denudation  the  raw 
edges  of  the  two  lateral  wounds  are  first  united,  and  the  sutures  tied  and 
cut  short,  thus  A  to  A,  and  B  to  B,  and  then  the  labio-perineal  denudation 
is  brought  together,  thus  a  to  a,  b  to  b,  c  to  c,  d  to  d  (Fig.  317). 

Bischoff  di-aws  dowTi  the  posterior  column  of  the  vagina,  dissects  off  a 
long  tongue-shaped  flap  extending  two  to  three  inches  up  the  canal,  and 
about  one  and  a  half  inch  wide,  and  then  denudes  laterally  from 
the  middle  of  each  nympha  down  to  the  perineum,  removing  all  interven- 


OPERATIONS  FOR  PROLAPSUS. 


533 


ing  mucous  membrane.  The  lateral  edges  of  the  central  flap  are  then 
sewed  to  the  edges  of  the  labial  wound,  first  on  one  side  and  then  on  the 
other,  and  finally  the  perineum  is  closed  (Fig.  318).     He  claims  specially 


Fig.  317. — ^Martin's  Denudation  for  Prolapsus.    Connecting  letters  are  onitcd. 

permanent  results  from  his  method.  I  have  never  done  it,  but  witnessed  its 
performance  twice  by  an  operator  who  used  the  knife,  which  perhaps  ac- 
counts for  the  exceeding  bloodiness  of  the  operation.  Of  com-se,  if  it  appears 
advisable,  anterior  colj)orrhaphy  may  have  jDrcceded  any  of  these  posterior 
operations,  although  these  latter  are  sup- 
posed to  suffice. 

Neugehauer,  of  Cracow,  claims  the  meth- 
od generally  known  as  Leforfs,  having  first 
performed  and  described  it  (after  a  sug- 
gestion of  Gerardin  in  1823)  in  18G7,  and 
having  had  twelve  successful  cases  up  to 
the  year  1881.  In  1876  Lefort  described 
substantially  the  same  operation,  and  has 
succeeded  in  introducing  it  under  his  name. 
The  operation  consists  in  uniting  the  an- 
terior and  posterior  walls  of  the  vagina  by  a  longitudinal  denudation,  thug 
forming  a  median  septum  upon  which  the  uterus  rides.  Of  course  subse- 
quent partui-ition  is  excluded  by  this  operation,  inasmuch  as  coition  is 


Fio.  318. — Bischoffs  Dcnndfttion  for 
rrolapstis.  a  b,  a  t\  surfocvs  united  ;  o,  poB- 
torior  vaginal  tongue. 


534 


GYNECOLOGICAL    OPERATTOlSrS. 


more  or  less  interfered  with.  It  is,  therefore,  applicable  only  to  elderly- 
women,  whose  sexual  functions  are  no  longer  active.  I  copy  Lefort's  de- 
scription :  "  The  utems  being  entu-ely  outside  of  the  vulva,  without  re- 
ducing it,  I  make  on  the  anterior  wall  of  the  vagina,  the  patient  lying  on 
the  back,  four  incisions,  cutting  out  a  portion  of  the  mucous  membrane 
which  yields  me  a  raw  surface  about  six  centimetres  long  by  two  wide 
upon  the  part  nearest  to  the  vulva.     Then  Kfting  toward  the  abdomen  the 

prolapsed  uterus,  so  as  to  see  the  pos- 
terior face  of  the  tumor,  I  make  on 
this  part  a  raw  surface  similar  to  that  on 
the  anterior  wall  (Fig.  320).  That  be- 
ing done,  I  in  part  replace  the  utenis  so 
as  to  bring  the  extremities  of  the  two 
raw  surfaces  in  contact  where  they  are 
nearest  the  uterus.  I  then  apply  on 
the  transverse  border  three  sutures, 
reuniting  longitudinally  the  anterior 
and  posterior  walls  of  the  vagina ;  I 
then  proceed  to  the  reunion  of  the 
lateral  borders  by  passing  from  each  a 
silver  thread,  traversing  the  border  of 
the  anterior  freshened  surface,  then 
the  corresponding  border  of  the  pos- 
terior freshened  surface.  A  thread 
being  placed  in  a  similar  manner  on 
the  opposite  side  and  at  the  same 
level,  it  is  sufficient  to  tie  these  su- 
tiu'es  to  increase  by  the  apposition  of 
the  opposite  vaginal  walls  the  reduc- 
tion of  the  uterus.  This  reduction  is 
completed  gradually  as  the  suttu'es 
are  put  in  place,  and  when  the  two  raw  surfaces  have  been  united  through- 
out theii-  extent,  theu'  reduction  is  complete  (Fig.  321).  The  threads  which 
have  served  as  sutures  for  the  transverse  border  nearest  the  uterus  being 
hidden  in  the  depth  of  the  vagina,  are  difficult  of  access  when  after  several 
days  union  is  effected  ;  therefore  it  is  wise  to  give  to  these  threads  suffi- 
ciently gi-eat  length  in  their  twisted  part,  in  order  to  seize  them  easily  when 
they  become  free  after  section  of  the  part  embraced  in  their  loops." 

The  Accidents  following  these  prolapsus  operations  are  similar  to  those 
outlined  as  occurring  after  ordinary  colpo-perineoiThaphy,  with  slightly 
greater  probabiHty  in  accordance  with  the  greater  extent  of  the  denuda- 
tions for  prolapsus.  Hegar  mentions  thi-ee  cases  of  secondary  arterial 
hemon-hage,  two  within  the  vagina,  and  one  at  the  entrance,  occurring  six 
hours  and  twelve  days,  respectively,  after  the  operation,  and  therefore°now 
ligates  larger  arterial  branches  which  may  be  divided.  Vaginal  hemor- 
rhage (which  must  not  be  mistaken  for  the  menstrual  flow,  or  the  reverse) 
must  be  arrested  by  astiingent  injections,  and  if  uncontroUable,  by  open- 


Pig.  319.— Lefort's  Method  for  Prolapsus.     Denu- 
dation on  anterior  vaginal  wall  (P.  F.  M.). 


OPERATIONS  FOR  PROLAPSUS. 


535 


ing  the  wound  cand  ligating  the  loleeding  vessel.  I  should  prefer  loose 
tamponade  before  resorting  to  that  extremity. 

Catan-h  of  the  bladder  would  not  be  uncommon,  if  the  precaution  were 
not  observed  always  to  introduce  the  catheter  by  the  eye,  after  thoroughly 
cleansing  the  vestibule.  If  the  patient  can  urinate  herself,  it  is  just  aa 
well  to  let  her  do  so,  merely  irrigating  the  vagina  and  vulva  afterward. 

Hegar  reports  two  deaths  from  pyemia  and  septicemia  out  of  one  hun- 
dred and  sixty  clinical  operations,  and  attributes  their  occiu'rence  to  the 
presence  of  septic  cases  in  the  clinic  at  the  time. 

Permanency  of  BesuUs. — The  numbe;*  of  operations  devised  for  pro- 
lapsus indicates  the  one  great  weakness  of  all  these  methods,  namely,  the 
gradual  stretching  of  the  adhesions  and  eventual  retui-n  of  the  displace- 


FiG,  320.— Section  View  of  Denndation.    A  C,  on  anterior  and  posterior  vaginal  walls  (after  Lef  orfs  method. ) 


ment.  Of  covirse  it  is  impossible  by  an  operation  (at  least  through  the 
vagina  ;  that  of  sewing  the  fundus  of  a  prolapsed  uterus  to  the  anterior 
abdominal  wall  has  been  proposed,  but  has  scarcely  become  popular  as  yet, 
even  in  this  age  of  laparotomies)  to  fix  the  utenis  itself  in  its  normal 
•position.  All  we  can  do  is  so  to  sti-engthen  the  lower  supports  of  the 
uterus,  the  vagina  and  its  pedestal,  the  perineum,  as  to  prevent  these 
parts  and  the  uterus  from  sinking  down  again.  The  operation,  tlierefore, 
which  best  accomplishes  this  purpose  is  the  one  to  be  selected.  The 
choice  seems  to  me  to  lie  between  the  methods  of  Simon,  Hegar,  and 
Fritsch.  Hegar  says  that  he  has  found  many  of  his  cases  still  perfectly 
well  from  four  to  ten  years  after  the  operation,  although  occupied  in  hard 
corporeal  labor.  Bischofif  reports  similar  results.  I  have  several  as  long 
as  two  to  five  years.  Of  course,  the  longer  the  patient  can  retain  the  re- 
cumbent position  and  abstain  from  exerting  herself,  the  sti'ouger  becomes 
the  cicatrix  and  the  more  permanent  will  be  the  result. 


536 


GYNECOLOGICAL    OPERATIONS. 


Parturition  will  naturally  be  the  severest  test  to  which  these  operations 
can  be  put,  and  many,  probably  the  majority,  will  succumb.  It  is  hardly 
to  be  expected  of  an  ai'tificially  constricted  vagina  that  it  should  with- 
stand agencies  which  a  healthy  primiparous  vagina  is  unable  to  resist, 
and  hence  it  is  not  to  be  wondered  at  if  a  relaceration  or  permanent  re- 
laxation of  the  vagina  and  perineum  occurs  durmg  dehvery.  The  surgeon 
should  warn  the  patient  of  this  danger,  and  advise  her  to  avoid  the  risk  of 
parturition  for  several  yeai'S  at  the  least,  and  if  the  event  does  present  itself. 


Fig.  321.— Section  View  of  Vaginal  Septum  formed  by  Lefort's  Operation  as  for  Prolapsus  Uteri. 

to  secure  competent  assistance  during  delivery.  Hegar  says  that  "  a  sub- 
sequent confinement  has  in  the  majority  of  his  cases  not  caused  a  relapse. 
Of  eleven  operations  of  whose  subsequent  labors  he  received  information, 
only  in  two  instances  did  a  relapse  occur."  I  have  no  experience  in  this 
respect  after  prolapsus  operations  ;  but  in  several  cases  of  secondary  peri- 
neorrhaphy I  have  succeeded,  by  the  liberal  use  of  vaseline  and  gradual 
preparatory  dilatation  of  the  perineum  with  the  fingers,  and  by  gently 
and  slowly  guiding  the  face  over  the  perineum  with  two  fingers  in  the  rec- 
tum, in  preventing  a  relaceration.  I  am  always  particular  to  caution  my 
patients  to  avoid  putting  the  perineum  to  the  test  in  less  time  than  two 
years  after  the  operation. 


LIST    OF    GYNECOLOGICAL    INSTRUMENTS.  537 


List   of    GrN-EcoLOGiCAL    Instecmexts     for    Office   Use   A^^)    for    JMixop. 

Operations. 

I.  Set  for  Office  Examinations  and  Ordinary  Use. 

1  Munde's  flange  Sims'  speculum. 
1  Vaginal  Sims'  speculum. 

3  Cyliudrical  hard-rubber  or  glass  (Ferguson's)  specula,  small,  medium, 

and  large  sizes. 
1  Sims'  depressor,  with  handle. 
1  Carved  uterine  dressing-forcep)S,  with  catch. 
.  2  Eight-angle  tenacula. 
1  Simpson's  sound. 
1  Emmet's  pure  silver  probe. 
1  Emmet's  repositor. 
1  Munde's  cervical  mucus  syringe. 

4  Munde's  hard-rubber  curved  apjDKcatora, 
1  Munde's  applicator-syringe. 

4  Straight  hard-rubber  screw  sticks. 
1  Sims'  hard-rubber  slide  applicator. 
1  Munde's  uterine  pencil-tube. 
1  Buttles'  scarificator  and  caustic  holder. 

1  Bangs'  small  dull  cui-ette. 

2  Thomas'  duU  curettes,  larger  sizes. 

2  Munde's  sharp  curettes,  medium  and  large  size. 

2  Munde's  large  dull  placental  cui-ettes. 
1  Munde's  placental  forceps. 

1  Palmer's  uterine  dilator. 

6  Albert  Smith's  retroversion  pessaries,  assorted  sizes. 

6  Munde's  bulb  retroversion  pessaries,  assorted  sizes. 

3  Thomas'  open-cup,  anteversion  pessaries,  assorted  sizes. 
3  Gehrung's  cystocele  pessaries,  larger  sizes. 

3  Glass  plugs,  different  sizes. 

1  Dozen  tupelo  tents,  assorted  sizes. 

1  No.  10  English  or  velvet-eye  rubber  catheter. 

1  Powder  Insufflator, 

lodofonn  ;  absorbent  cotton ;  tampons  ;  alum-glycerine,  1  to  8  ;  tincture 
of  iodine,  pure  and  compound;  concentrated  solution  of  cai-bolic 
acid  ;  glycerine  ;  vaseline. 

n.  Roll  of  Instruments  for  Minor  Operations,  chiefly  Laceration  of  Cervix 

and  Penneum. 

2  Emmet's  small  curved  cei-v'ix  scissors,  right  and  left. 

2  Emmet's  perineum  scissors,  right  and  left  curve  or  flat. 
1  Emmet's  or  Sims'  needle-holder. 


538  LIST    OF    GYNECOLOGICAL   INSTRUMENTS. 

2  Solid  steel  cervix  operation  tenacula. 
1  Munde's  counter-pressure  liook. 

1  Eininet's  wire  twisting  forceps. 

1  Sims'  shield. 

1  Thomas'  tissue-forceps. 

1  Long  straight  scissors. 

1  Stout  wire  scissors. 

6  Schnetter's  cervix  needles,  long  and  sliort. 

6  Sims'  cervix  needles,  long  and  short. 

12  Straight  darning  needles,  for  perineum. 

3  Long  Koeberle's  pinces  hemostatiques. 
3  Short  Koeberle's  pinces  hemostatiques. 

12  Metal  sponge-holders. 

2  Eight  angle  tenacula. 

1  Uterine  dressing-forceps,  with  catch. 

1  Simpson's  sound. 

1  Munde's  sharp  curette. 

1  Buttles'  scarificator. 

1  Sims'  uterotome. 

1  Palmer's  uterine  dilator. 

3  Glass  plugs. 

1  Long-handled  bistouiy,  straight,  blunt  point. 

1  Long-handled  bistoury,  sharp  point. 

One-half  dozen  tuj)elo  tents. 

Braided  silk,  three  sizes  ;  catgut,  three  sizes. 

Pm-e  silver  wire,  four  coils,  Nos.  26  and  27  ;  one  coil.  No.  33. 

A  dozen  common  fine  carbolized  sponges,  well  cleaned. 

To  he  Gamed  m  Satchel  with  above  lioll. 

1  ■Munde's  short,  flat,  broad,  Sims'  speculum,  for  operations. 
1  Ordinary  Sims'  speculum. 
1  Short-handled  depressor. 
1  Elastic  catheter. 

1  Ether-inhaler  and  Squibb's  sulphuric  ether. 
Vaseline  ;  carbohc  acid  ;  alum-glycerine  ;  finely  powdered  iodoform  in 
insufflator  ;  half  a  dozen  nitrite  of  amyl  pearls. 

in.  Gynecological  Satchel  with  Instruments  for  Examimtions  and  Ordinary 

Treatment. 

1  Mundo's  flange  speculimi. 

1  Depressor. 

2  Curved  catch  dressing-forceps. 
2  Examining  tenacula. 

2  Cun-ed  rubber  applicators. 
2  Straight  rubber  sticks. 


LIST    OF    GYNECOLOGICAL    INSTRUMEXTS.  539 

1  Slide  applicator. 

2  Thomas'  dull  curettes,  2  sizes. 
2  Mimde's  sharp  curettes,  2  sizes. 
2  Munde's  placental  curettes. 

1  Munde's  placental  forceps. 

1  Hinged  Simpson's  sound. 

1  Palmer's  dilator. 

1  Uterine  scarificator. 

1  Glass  or  hard-rubber  cylindrical  speculum,  medium  size. 

6  Retroversion,  3  anteversion  pessaiies,  different  sizes. 

1  Insufldator  filled  with  iodoform. 

Absorbent  cotton  ;  string  tampons  ;  disk  tampons. 

6  Bottles  in  boxwood  cases,  containing  glycerine,  vaseline,  alum-glycer- 
ine (1:8)  ;  carbolic  acid,  tincture  of  iodine,  solution  of  the  persulphate 
of  iron. 

rV.  Pocket-case  for  Examinations  and  Applications. 

1  Dawson's  double-hinge  Sims'  speculum. 

1  Double  depressor. 

2  Tenacula. 

2  Munde's  hard-rubber  applicators. 
2  Straight  hard  rubber  sticks. 
1  Curved  catch  dressing-forceps. 
Absorbent  cotton  ;  tampons. 


INDE 


Acid,  eJiromic,  danger  of  systemic  shock 
from  local  applications  of,  167 
nitric,  application  to  the  endometrium, 

243 
safety  of  application  to  endometrium, 
257 
Abdomen  and  pelvis,  mensuration  of.  117 

inspection  of,  32 
Abdominal  and  pelvic  tumors,  aspiration 

of,  117 
Abdominal  palpation,  36 
position,  25 

striae,  siornificance  of,  33 
supporters,     ceinture    hypogastrique, 
349 
home- made,  348 
Pinard's,  347 

Thomas'   wooden  pad  for  antever- 
sion,  349 
Age,  advanced,  operative  procedures  in,  8 
Alterative  applications,  173,  180,  233 
Amenorrhea,  229 

Anesthesia,   abdominal  palpation   during, 
37 
during  insertion  of  sponge-tents,  274 
daring  use  of  dull  curette,  313 
in  uterine  dilatation,  205 
propriety  of,  in  minor  operations,  7 
Anesthetics,  438 

Application  of  medicinal  agents  to  the  en- 
dometrium, 218 
agents  most  used,  235 
by  applicator  syringe,  245 
by  injection,  247 
by  medicated  tents,  249 
cases  of  shock  after.  256 
choice  of  method,  253 
conditions  necessary  for,  236 
counter-indications  and  dangers,  255 
nitric  acid,  243,  357 
ointments,  353 
on  a  caustic  holder,  353 
on  applicators,  237,  243 
precautions,  254 

therapeutic  value  of,  257  ' 

Application  of  medicinal  agents  to  vagina 
and  cervix  : 
alteratives,  173 
astringents,  173 


Application  of  medicinal  agents  to  vagina 
and  cervix  : 

by  injection,  137 

by  insufflation,  193 

caustics,  173 

disinfectants,  188 

emollients,  173 

fluids,  168 

hydragogue.  173 

narcotics,  173 

ointments,  188 

styptics,  173 

suppositories,  191 

through  specula,  158 
Applicator  syringe,  245 
Applicators,    intra-uterine,    varieties    and 
mode  of  wrapping,  237 

manner  of  using.  239 
Areolar  hyperplasia,  180,  227 

vaginal  tamponade  in,  211 
Aspirating  syringe,  Munde's,  121 
Aspiration  of  abdominal  and  pelvic  tumors, 

117 
Astringent  applications,  173,  177,  232 
Auscultation    in   gynecological  diagnosis, 
35 

Bedsores,  prevention  of,  418 
Bimanual  examination,  58 

counter-indications,  58 

indications  for,  58 
Bladder,  injections    into   the,  indications 
and  method,  134 

injections  into  the,  materia  medica  of, 
136 

instrumental  examination  of,  67 
Bougies,  intra-uterine.  249 

tube  for  introducing,  into  nterus,  250 
Breasts,  inspection  of,  33 

Cancer,    scirrhus,   diagnosis  by  sponge- 
tent,  289 
Carcinoma  of  the  cervix,  use  of  dull  cu- 
rette in,  313 
Cas'^-schedule  for  gj-necological  histories, 

124 
Catalepsy  due  to  lacerated  cervix.  442 
Catarrh,  cervical,  causes,  appearanccj  and 
symptoms,  219 


543 


INDEX. 


Catarrh,  cervical,  caused  by  narrow  exter- 
nal OS.  222 
prognosis  of,  223 
therapeutic  agents  used  in,  221 
Catarrhal   erosion   of  the  cervix,    "gran- 
ular" and  "follicular"  erosion,  220 
Catheter,  Goodman-Skene's  self-retaining, 
130 
Sims'  sigmoid,  130 

Skene's  reflux  for  injecting  bladder, 
185 
Catheterization,  127 

when  requiring  exposure   of  the   pa- 
tient, 129 
Caustics,  application  of,  to  endometrium, 
232 
application  of,  to  vagina  or  cervix,  162, 

173 
manner  of  applying   and  indications 
for  use  of,  174 
Cautery,  actual,  application  of,  165 

varieties  of,  163 
Cellulitis,  chronic,  180 

due  to  lacerated  cervix,  433 

vaginal  tamponade  in,  211 

Cervical  canal,  discision  of  the,  297 

division  of  the,  antero-posterior,  300 
antero-posterior,  benefits  of,  304 
antero  -  posterior,     counter  -  indica- 
tions, 304 
antero-posterior,  dangers  of,  303 
antero-posterior,  indications  for,  300 
antero-posterior,  operation  for,  302 
bilateral,  297 
bilateral,  benefits  of,  804 
bilateral,  dangers  of,  303 
bilateral,  indications  for,  297 
bilateral,  operation  for,  298 
Cervical  catarrh,  caused  by  narrow  exter- 
nal OS,  treatment  by  division  of  the 
cervix,  222 
causes,  appearance,  and  symptoms,  219 
prognosis  in,  223 
therapeutic  agents  used  in,  221 
Cervical  cavity,  dilatation  of,  and  retention 
of  mucus  in,  223 
hemorrhage  from,  160 
Cervical  mucus  syringe,  221 
Cervical  specula,  243 
Cervix,  application  of  leeches  to  the,  323 
of  powders  to  the,  160 
applications  to,  alteratives,  173,  180 
astringents,  173,  177 
by  injection,  137 
by  insufflation,  193 
cantbaridal  collodion,  185 
caustics,  174 
disinfectants.  188 
emollients,  173,  187 
escharotics,  169 
hydragogue,  173, 185 
iodine,  182 
iodoform,  184 
narcotics,  173,  187 
ointments,  188 
styptics,  177 


Cervix,  applications  tothe  catityof  the,  coun- 
ter-indications and  dangers,  224 
indications  for,  218 
methods,  225 
precautions,  224 

cancer  of,  use  of  sharp  curette  in,  318 

carcinoma  of  the,  use  of  dull  curette 
in,  313 

conditions  of  the,  recognizable  by  spec- 
ular examination,  77 
recognizable  by  vaginal  touch,  49 

congenital  malformation  of,  448 

cystic  hyperplasia  of  the,  scarification 
in,  326 

discision  of  the,  crucial,    of  external 
OS,  295 
for  hemorrhage  with  fibroids,  293 
in  anteflexion  of,  292 
in  contracted  external  os,  292 
in  elongation  of  anterior  lip  of,  293 
in  latero-versions  and  flexions,  293 

division    of   the,    free,   of    the   intra- 
vaginal  portion,  295 
free,    of  the   intravaginal  portion, 

dangers,  303 
superficial,  of  external  os,  293 
superficial,  of  the  intravaginal  por- 
tion, 305 

external  os,  occlusion  of,  by  granula- 
tions, 308 

erosion  of,  catarrhal,  granular  and 
follicular.  220 

excision  of  the,  wedge-shaped,  308 

fatal  secondary  hemorrhage  after  am- 
putation of  epitheliomatous,  320 

fissured,  nearly  always  due  to  parturi- 
tion, 431 

hyj)€rtrophic  elongation  of  the  intra- 
vaginal portion  simulating  prolap- 
sus, 528 

hypertrophic  elongation  of,  with  ap- 
parent prolapse  of  the  vagina  sim- 
ulating true  prolapsus,  527 

hypertrophic,  simulating  prolapsus, 
amputation  of,  by  galvano-cautery 

_  loop,  530 

injection  of  medicinal  substances  into 
the  tissue  of  the,  327 

injuries  inflicted  on  the,  by  the  tenac- 
ulum, 114 

lacerated,  430 

catalepsy  due  to,  442 

cicatricial  plug  in,  438 

cystic  and  papillary  hyperplasia  of, 

simulating  epithelioma,  447 
danger  of  malignant  degeneration  of , 

434 
definition  of,  430 
degrees  of.  439 
diagnosis  of,  443 
differential  diagnosis  of,  446 
dyspareunia  due  to.  449 
ectropion  of,  433,  438 
etiology  of.  430 
evil  results  of,  448 
frequency  of,  434 


INDEX. 


543 


Cervix,  lacerated,  hemichorea  due  to,  443 
hemicrania  due  to,  442 
hyperplasia  due  to,  432 
hystero-neuroses  due  to,  432,  441 
instruments  used  in  closure  of  a, 

459 
necessity  for  examination  of,  after 

labor,  412,  431 
needles  used  in  closure  of  a,  460 
lacerated,  operative  closure  of,  458 
assistants,  461 
after-treatment,  468 
counter-indications  to  the,  472 
danger  of  menstruation  immediately 

following,  474 
danger  of  pelvic  cellulitis  and  peri- 
tonitis following,  475 
danger  of  primary  hemorrhage  after, 

473 
danger    of    secondary   hemorrhage 

after,  474 
danger  of  sloughing  after,  474 
danger  of  too  thorough  denudation, 

473 
details  of,  462 
dystocia  from,  at  subsequent  labor, 

477 
excision  of  "  Ovula  Nabothii,"  463 
failure  of  union  of  lips  of  wound,  475 
influence  on  sterility,  471,  476 
indications  for,  456 
introduction  of  sutures,  464 
menstruation  before  removal  of  su- 
tures, 470 
possible  dangers  of,  473 
possible  evil  results  after,  475 
possible  modifications   of  operative 

details,  466 
precautions  during,  468 
preparation  of  patient,  461 
proportion  of  failures,  476 
relaceration  at  a  subsequent  labor, 

477 
removal  of  sutures,  469 
results  achieved  by  the,  470 
without  anesthesia,  461 
lacerated,  ovaritis  and  cellulitis  due  to, 

432 
pathology  of,  432 
pathological  changes  in,  433,  437 
physician  usually  not  to  blame  for, 

431 
possible  results  if  trachelorrhaphy  is 

not  performed,  478 
production  of,  by  forceps,  430 
prognosis  of,  449 
reflex  neuroses  due  to,  441 
remote  and  immediate  causes  of,  430 
significance  of,  as  a  cause  of  uterine' 

disease,  450 
statistics   of    per    cent,     requiring 

treatment,  452 
sterility  due  to,  448 
subinvolution  due  to,  433 
symptoms  of,  440 
treatment  of,  indications  for,  453 


Cervix,  lacerated,  treatment  of,  palliative, 
453 
treatment  of,  radical,  456 
varieties  of,  435 

wedge-shaped  excision  in  hyperpla- 
sia of,  467 
manner  of  applying  caustics  to,  173 
precautions  in  the  use  of  cauetics  to 

the,  167 
position  of,  in  displacements  of  uterus, 

51 
substances  applied  to  the,  through  the 
speculum,  and  manner  of  applying 
them,  159 
ulceration  of  the,  448 
Chorea  caused  by  lacerated  cervix,  443 
Coitus,  painful,  caused  by  lacerated  cervix, 
449 
painful,  caused  by  lacerated  perineum, 

484 
vaginal  injections  after,  153 
while  wearing  a  pessary,  354,  370 
Colporrhaphy,  anterior,  517 
indications  for,  518 
operations  for,  519 
posteiior,  512 

indications  for,  513 
operations  for,  514 
Simon's  fenestrated  speculum  for, 
515 
Confinement,  operations   on   the   genitals 

after,  411 
Coprostasis,  38 
Couches  for  examination,  28 
Curette,  blunt,    indications   and   counter- 
indications  for  the  diagnostic  use  of 
the,  110 
dull,  anesthesia  during  use  of  the,  313 
counter-indications  to  the  use  of  the, 

315 
dia'^nosis  of  material  removed  bv, 

310 
indications  for  the  use  of  the,  309 
manner  of  using,  313 
Mundo's  large,  for  removal  of  pla- 
centa after  abortion,  315 
only  to  be  used  at  patient's  home, 

313 
removal  of  diffuse  sarcoma  by  the, 

312 
removal  of  retained  placental  villosi- 

ties  by  the,  312 
Thomas',  309 
use  of,  in  carcinoma  of  the  cervix, 

313 
use  of.  in  chronic  hyperplastic  endo- 
metritis. 310. 
sharp,  with  flexible  shank.  316 

with  flexible  shank,  indications  for 

the  use  of.  317 
with    inflexible    shank,  dangers  in 

using.  32n 
with  inflexible  shank,  indications  for 

the  use  of,  318 
with   inflexible   shank,    method  of 
using,  319 


544 


IXDEX. 


Curette,  sJiarp,  Sims',  316 
subacute,  Recamier's,  316 
Thomas'  blunt,  110 
use  of  the,  lor  diagnostic  purposes, 
110 
Curetting  of  the  uterine  cavity,  308 
Cylindrical  specula,  73 
Cystocele,  517 

and   urethrocele,  operation  for,  Em- 
met's, 521 
caused  by  perineal  laceration,  483 
diagnosis  of,  517 
operation  for ,  Emmet's,  520 
Stoitzs,  522 
details  of,  519 
pessaries  for,  387 
use  of  pessary  for,  518 
Cysts,  diagnostic  aspiration  of,  119 

DlAGNOSTS,  by  vaginal  touch,  46 
gynecological,  auscultation  in,  35 

percussion  in,  35 
of  abdominal  tumors  by  means  of  the 

aspirator,  118 
of  gynecological  cases,  general  consid- 
erations influencing  the,  1 
significance  of  pain  in,  12 
Digital  examination,  41 

eversion  of  rectum,  62 
Dilatation   of    the   urethra,    dangers   and 
counter-indications,  133 
indications  and  operations  for,  130 
of  the  uterus,  by  cutting  instruments 

(see  Uterus),  290 
without    cutting     instruments     (see 
Uterus,  258 
Dilators,  urethral,  Simon's,  132 
Discision  of  the  cervical  canal,  297 
Disinfection,  427 

Disinfectant  applications,  188,  234 
Displacements  of  the  uterus  (see  Uterus'^, 

329 
Division  of  the  cervical  canal,  300 
Dorsal  recumbent  position,  19 
Douche,  hot  vaginal,  method  of  using  (see 
Vaginal  Injections),  145 
rules  for  using,  146 
Duck-bill  speculum,  82 
Dysmenorrhea,  effects   of  uterine  dilata- 
tion in,  280,  291 
Dyspareunia,  due  to  cervical  laceration,  449 

due  to  perineal  laceration,  484 
Dystocia  from  trachelorrhaphy,  477 

Electric  light,  portable,  123 
Emollient  applications,  173,  187 
Endemics,  operations  during,  410 
Endometritis,  chronic,  226 

chronic  hyperplastic,  use   of  dull  cu- 
rette in,  310 
diagnosis  of,  by  means  of  vaginal  tam- 
pon, 217 
polyposa,  310 
Endometrium,  applications  to  the,  218,  236 
agents  most  used,  235 
by  applicator  syringe,  245 


Endometrium,  applications  to  the,  by  injec- 
tion, 247 
by  medicated  tents  or  bougies,  249 
cases  of  shock  after,  256 
choice  of  method,  253 
conditions  necessary  for,  236 
counter-indications     and     dangers, 

255 
nitric  acid,  242,  257 
ointments,  252 
on  a  caustic-holder,  253 
on  applicators,   advantages  and  dis- 
advantages, 243 
on  applicators,  through  the  dilated 

cervical  canal,  241 
on  applicators,  through  the  undUat- 

ed  cervical  canal,  237 
precautions,  254 
therapeutic  value  of,  257 
scarification  of  the,  326 
tamponade  oj  the,  247 
therapeutic  agents  applied  to  the,  alter- 
atives, 233 
astringents,  233 
caustics,  232 
disinfectants,  234 
galvanism,  233 
narcotics,  234 
oxytocics,  235 
stimulants,  234 
styptics,  232 
time  and  frequency  of  applications  to 
the,  235 
Endotrachelitis,  caused  by  narrow  external 
OS,  treatment  bv  division  of  the  cer- 
vix, 222 
causes,  appearance,  and  symptoms,  219 
prognosis  in,  223 
therapeutic  agents  used  in,  221 
Enemata,  glycerine,  187 
Endoscope,  urethral,  68 
uterine,  109 

vesical,  Eutenberg's,  70 
Escharotics,    indications,    mode    and   fre- 
quency of  application,  precautions,  dan- 
gers, and  restrictions  in  use  of,  169 
Ether,  inhalers  for,  429 
Etherization,  preparation  of  patient  for,  429 
Erect  position,  27 

examination  in  the,  54 
Erosion  of  the  cervix,  catarrhal,  granular 

and  follicular,  220 
Ergot,  hypodermic  injection  of,  406 
Examination,  bimanual,  58 

by   introduction   of  whole  hand  into 

rectum,  56 
by  means  of  instruments,  65 
by  rectal  touch,  54 
by  recto-vaginal  touch,  55 
by  reflected  light,  122 
by  vesical  touch,  56 
in  lateral  and  latero-abdominal  posi- 
tion, 53 
in  the  erect  position,  54 
in  knee-chest  position,  53 
methods  of  local,  16 


INDEX. 


545 


Examination,  method  of  taking  patient's 
history  in,  1 1 

most  favorable  time  for,  18 

necessity  for  local,  after  parturition, 
413 

of  the  rectum  with  the  speculum,  115 

of  the  uterus  with  sound  and  probe,  95 

of  vaginal  fornix,  51 

positions  for,  18 

recto-abdominal,  61 

specular,  difficulties  in  making,  91 

vaginal,  2 

vaginal,  digital,  41 

vaginal,  specular,  72 

vagino-abdominal,  58 

vesico- abdominal,  61 

verbal,  of  patient,  10 

without  instruments,  inspection,  32 
Examining  tables,  29 
Expanding  specula,  78 

Fecal  incontinence,  caused  by   perineal 

laceration,  485 
Fistula3  after  perineorrhaphy,  510 

Galvanism  of  endometrium,  233 
Genitals,  inspection  of,  33,  48 
Genupectoral  position,  25 
Gestation,  indications  for  operations  dur- 
ing, 411 
Glands,  urethral,  inflammation  of  the,  34 
Glycerine,  185 

enemata,  187 
Gynecological  case-schedule,  125 

diagnosis,  percussion  in,  35 

Hemichorka  due  to  lacerated  cervix,  443 
Hemicrania  due  to  lacerated  cervix,  442 
Hemorrhage,  arrest  of,  420 
after  trachelorrhaphy,  473 
case  of  fatal  secondary,  after  amputa- 
tion of  epitheliomatous  cervix,  320 
from  cervical  cavity,  160 
proper  manner  of  tamponing  the  va- 
gina for,  and  method  of  removal  of 
tampons,  215 
uterine,  237 
Hemostatic  forceps,  425 
Hemorrhoids,    removal   of,  when    closing 

cervical  or  perineal  rent,  414 
Histories,  gynecological,  case -schedule  for, 

124 
Hydragogue  applications,  173 
Hymen,  intact,  as  proof  of  virginity,  48 
rupture  of,  during   vaginal   examina- 
tion, 343 
Hyperplasia,  areolar,  180 

of  the  cervix,  wedge-shaped  excision 

in,  467 
of  the  uterus,  227 
of  the  uterus,  due  to  lacerated  cervix, 

432 
vaginal  tamponade  in,  211 
Hypodermic  injection  of  ergot,  406 
Hypodermic  syringe  for  diagnostic  aspira- 
tion, 120 

35 


Hystero-neuroses  due  to  lacerated  cervix, 
433,  441 

Indagation,  uterine,  pathological  condi- 
tions calling  for,  109 

vaginal,  45 
Injections  into  the  bladder,  Indications  and 
method,  134 

materia  medica  of,  130 
Injections,  vugituil,  137 

after  coitus,  153 

alterative,  151 

amount  of  fluid  to  be  used,  143 

astringent,  149 

cleansing.  153 

composition  of,  147 

counter-indicati ons  and  dangers  of ,  1 57 

disinfectant,  148 

emollient,  153 

hot,  145 

hot,  in  pelvic  congestion.  155 

indications  for,  and  utility  of,  153 

manner  of  using,  141 

sedative,  153 
Inspection  of  abdomen,  33 

of  breasts,  33 

of  genitals,  33,  48 

of  vaginal  secretions,  34 
Instruments,  disinfection  of,  66 

examination  by  means  of,  65 

list  of.  for  office  use  and  for  minor  op- 
erations, 537 
Intertrigo,  remedy  for,  317 
Iodine,  tincture  of,  application  of,  to  cer- 
vix, 183 
Iodoform  and  chloral,  184 
Iodoform,  deodorizers  of,  161 
Irrigators,  vaginal.  138,  145 

proper  form  of  tube  for,  146 

Knee-chest  or  elbow  position,  examina- 
tion in,  53 
applications  to  vagina  in  the,  177 

Lactation,  indications  for  operations  dur- 
ing, 413 

Laminaria  tents,  277  (see  Tents). 

Lateral  position.  33 

Latero-abdominal  position,  34 

Lateral  and  latero-abuomiual  position,  ex- 
aminations in,  53 

Leech,  artificial,  334 

Leeches,  application  of,  to  the  cervix,  323 

Light,  electric,  portable,  13:5 

examination  by  reflected,  123 

Medicated  tents,  249 
Mensuration  of  the  abdomen  and  pelvis.  1 17 
Menstrual  period,  time  for  operative  pro- 
cedures in  relation  to  the.  4 
vaginal  examination  during  the.  3 
washing  the  genitals  during  the,  4 
Menstruation,  significance  of  pain  accom- 
panving,  16 
before'  removal  of  sutures  in  trache- 
lorrhaphy, 470 


546 


INDEX. 


Metrotome,  Greenhalgh's,  290 

Peaslee's,  'SOU 

Studley's,  290 
Mundu's    combination    Sims'   and    Nott's 
speculum,  93 

Narcotic  applications,  173,  187,  234 
Needle-holder.  424 
Needle,  Peaslee's,  421 
Needles,  gynecological,  420 

methods  of  threading,  for  wire  sut- 
ures, 423 
Neuroses  due  to  lacerated  cervix,  441 
Nitrate  of  silver,  precautious  in  the  use  of 
strong  applications  of,  167 
use   of,  in   inflammatory   diseases   of 
vagina  and  uterus,  174 
Noeggerath's  vulsella-f creeps  for  dislocat- 
ing uterus  downward,  118 

Ointments,  application  of,  188,  190 
Oophoro-salpingectomy,    indications    for, 

415 
Oophoritis,  181 

Operation,  Battey's,  when  indicated,  415 
best  time  for  performance  of  an.  409 
Emmet's,  for  lacerated  <2ervix,  456 
Emmet's,  for  lacerated  perineum,  505 
Peaslee's,  for  superficial  trachelotomy, 

305 
Simon's,  for  complete  perineal  lacera- 
tion, 503 
Simpson's,  for  discision  of  the  cervi- 
cal canal,  297 
Sims',    for  discision  of  the    cervical 

canal,  300 
Tait's,  when  indicated,  415 
Operations,  choice  of  place  for,  416 

constitutional  taints  contra-indicating, 

417 
diet  after,  418 
disinfection  for,  427 
during  pregnancy,  4 
during  the  puerperal  state,  6 
general  considerations  on.  409 
gynecological,  conditions  complicating, 

8 
minor,  anesthesia  in,  7 
moral  effect  of,  7 

plastic,  vaginal  irrigation  during,  157 
preparatory  treatment  for,  417 
temperament  as  affecting  feasibility 

of,  0 
use  of  morphia  after,  430 
Operative  procedure  in  advanced  age,  8 
procedures,  proper  time  for,  in  relation 
to  the  menstrual  period,  4 
Os,    external,    sterility    caused    by    con- 
stricted, 222 
Ovarian  tumors,  when  to  operate  on.  414 
Ovaries,  displaced,  reposition  of  the,  342 
indications  for  removal  of,  415 
prolapsed,  Munde's  pessary  for,  380 
prolapsus  of,  pessaries  for.  386 
Ovaritis,    chronic,   vaginal  tamponade  in, 
^11 


Ovaritis,  due  to  lacerated  cervix,  432 
Ovary,  palpation  of  the,  47 

prolapsed,  influence  on  selection  of  a 
pessary,  364 
"  Ovula  Nabothi,"  excision  of,  in  trache- 
lorrhaphy, 463 
Oxytocics,  application  of,  to  endometrium, 
235 

Pain,  significance  of,  in  diagnosis,  12 

significance    of,  Avhen    accompanying 
menstruation,  16 
Palpation,  abdominal,  36 

diagnostic,  of  tumors,  39 
Pelvic  peritonitis,  vaginal  tamponade  in,  211 

tumors,  aspiration  of,  117 
Pessaries  ;  abdominal  supporters,  346 

counter-indications  to  the  use  of,  353 

elastic  lever,  379 

flexible,  351 

for  ante-displacements  of  uterus,  371 

for  cystocele,  387 

for  lateral  displacements,  386 

for  prolapsed  ovaries,  386 

for  prolapsus  uteri,  387 

for  prolapsus,  choice  of,  390 

for  prolapsus,  objections  to,  390 

for  rectocele.  387 

for  retro-displacements,  377 

general  considerations  influencing  the 
selection,  application,  and  manage- 
ment of,  354 

general  indications  for  use  of,  352 

general  rules  for  introduction  and 
supervision  of,  865 

hard-rubber,  method  of  heating  to 
change  shape  of,  351 

how  to  adjust,  381 

in  unmarried  women,  852 

lever,  causes  of  failure  of,  357 

lever,  cases  where  they  act  by  direct 
support,    359 

lever,  points  of  support  of,  358 

lever,  necessity  for  proper  choice  of 
size  and  curve,  in  selection  of,  358 

mode  of  action  of,  355 

necessity  for  mechanical  dexterity  in 
the  fitting  of,  360 

retroversion,  introduction  of,  381 

Ste77i,  898 

authorities  for  and  against,  402 
counter-indications  for  the  use  of, 

401 
dangers  in  the  use  of,  402 
indications  for  the  use  of,  400 
length  of  time  to  be  worn,  405 
mode  of  introduction,  404 
precautions  in  the  use  of,  403 
results  of  use  of,  403 

Thomas'  wooden  pad  for  anteversion, 
849 

use  of,  during  pregnancy.  353 

use  of,  in  sterility  due  to  displacement, 
353 

use  of,  where  uterus  is  bound  down  by 
adhesion.s,  358 


INE-EX. 


547 


Pessaries,  vaginal,  curative  results  from, 
392 
vaginal,  curative  results  from,  statis- 
tics of,  893 
vaginal,  dangers  from,  391 
vaginal,  materials  used  for,  350 
vaginal,  resumo  of  rules  for  use  of,  39G 
vagino-abdominal,  389 
which  act  by  a  lever  action,  35G 
which  act  by  their  size,  limits  of  use 

of,  355 
which  act  only  by  the  direct  support 

they  give.  355 
Pessary,  a  well-fitting  one  should    never 

give  pain,  3G6 
Albert   Smith's,    Gehrung's  modifica- 
tion of,  379 
Albert  Smith's  retroversion,  377 
coition  while  wearing  a,  354,  370 
condition  of  perineum  as  influencing 

selection  of,  363 
Emmet's  method  of  selecting  a.  360 
Fowler's  retroversion,  385 
Gehrung's  anteversion,  manner  of  use, 

371 
gradual  adaptation  of  vagina  to  a,  365 
Graily   Hewitt's   anteflexion,    cradle, 

377 
Hewitt's  retroversion,  379 
Hitchcock's  anteversion,  375 
Hodge's  double-lever  retroversion,  377 
importance  of  always  replacing  uterus 

before  applying  a,  365 
influence  of  prolapsed  ovary  on  selec- 
tion of,  364  I 
lever,  disadvantage  of  usual  method  j 

of  introduction  of,  384 
lever,  introduction  of,  382 
lever,     resume   of  steps  of  introduc- 1 

tion  of,  385  i 

Munde's    bulb,    for  retroflexion    and 

prolapsed  ovaries,  380 
necessity  for  cleansing  injections  while 

wearing,  368 
necessity  for  removal  of,  from  time  to 

time,  369 
Noeggerath's  retroversion  bulb,  370 
patient   always   to   be    informed   that 

she  is  wearing  a,  366 
points  to  consider  in  selecting  variety, 

size,  and  shape  of,  360 
removal  of,  when  covered  by  granula- 
tions, 370 
"  sleigh,"  for  retroversion,  379 
Studley's  ring,  for  retroversion,  379 
tenderness   in  parametrium  or  uterus 

as  influencing  wearing  of  a,  363 
Tiemann's,  for  prolapsus.  390 
Thomas'  anteflexion,  closed  cup,  375 
Thomas'  anteversion,  open  cup,  376 
Thomas'  anteversion  '"buckle,"  374 
Thomas'  bulb  retroflexion,  379 
Thomas'  cup  and  stem  for  prolapsus, 

390 
vaginal  tamponade  as  a  substitute  for, 

308 


Percussion  in  gynecological  diagnosis,  35 
Perineum  and  cervix,  lacerated,  closure  o£ 

both  at  the  same  time,  413 
Perineum,   licemted,    advantages   of  pri- 
mary closure  of,  412 

closure  of,  several  hours  after  labor, 
413 
XaceniUon  of  the,  anatomical  relations 
and  diagnosis  of.  480 

complete,  colitis  caused  by,  485 

complete,  fecal  incontinence  caused 
by,  485 

dy.spareuuia  caused  by,  484 

frequency  of.  479 

pathological  results  of,  481 

primary  operations  for  closure  of,  486 

rectocele   and  cvstocele  caused  by. 
483 _  '  ^' 

retention  of  air  in  vagina  in,  483 

secondary  operation  for  closure  of, 
492 

sterility  caused  by,  484 

subinvolution  of  the  vaginal  walls  in, 
483 

treatment  of,  486 

varieties  and  degrees  of,  479 
necessity  for  immediate  examination 

of.  after  parturition,  412 
Perineorrhaphy,  fvimary,  operations  for, 
486 

single  suture,  operation  for,  487 
secondary,  assistants,  491 

after-treatment  for,  497 

cellulitis  after,  511 

dangers  and  evil  results  of,  508 

denudation  for.  494 

Emmet's  new  method  for,  505 

fistulaj  after,  510 

hemorrhage  during  and  after,  509 

history  of.  489 

indications  for,  488 

inflammation  after,  509 

inflammatory  edema  of  wound  after, 
509 

instruments  used  for,  491 

management  of  bowels  after,  4  98 

method  of  securing  relaxation  of  the 
peruieum  in,  508 

objects  of,  489 
secondary  operation  for  central  lacera- 

ti'>Uy  507 
secondary  operation  for  complete  lacera- 
tion. 499 

after-treatment,  502 

details  of.  501 

denudation  for.  503 

failure  of  sphincter  to  unite.  510 

pas-sage  of  sutures  in.  5(t2 

passage  of  rectal  sutures  in.  503 

passage  of  vaginal  sutures  in.  504 

preparation  of  the  patient  for,  500 

Simon's,  503 
secondary  operation  for  incomplete  lac- 
eration, 492 

passage  of  sutures  in,  495 

pockets  left  after,  511 


548 


INDEX. 


Perineorahaphy,   secondary  operation  for 
incomplete  laceration,  position  of 
patient  and  operator  for,  491 
preparatory  treatment  for,  490 
proportion  of  failures  after,  512 
removal  of  sutures  in,  499 
rise  of  temperature  after,  511 
septic  infection  after,  509 
sources  of  failure  of,  508 
stretching  of  sphincter  before,  508 
technical  details  of,  494 
tertiary,  507 
Placental  villosities,  retained,  curetting  of, 

312 
Porte -tampon,  202 
Position,  abdominal,  25 
dorsal  recumbent,  19 
erect,  27 

erect,  examination  in  the,  54 
genupectoral,  25 
knee-chest  or  elbow,  examination  in, 

53 
lateral,  23 

latero- abdominal,  24 
lateral   and   latero-abdominal,  exami- 
nation in,  53 
Sims',  advantages  of,  25 
Poultice,  vaginal,  162 
Pregnancy,  operations  during,  4 
local  manipulations  during,  5 
when  to  operate  during,  411 
Prolapsus   uteri,   hypertrophic  cervix   in, 
amputation  of,   by  galvano-cautery 
loop,  530 
hypertrophic  elongation  of  the  intra- 
vaginal  portion  of  the  cervix  simu- 
lating, 528 
operation  for,  accidents  following  the, 
534 
indications  for  the,  528 
Bischoff's,  532 
Fritsch's.  582 
Hegars,  532 
Martin's,  532 

modified  Stoltz-Simon,  530 
Neugebauer's,  533 
Leforfs,  533 
objects  of  the,  529 
permanency  of  results  in,  535 
symptoms  and  significance,  528 
operations  for,  530 
et  vaginae,  hypertrophic  elongation  of 

the  cervix  simulating,  527 
et  vagiuEe,  varieties  and  degrees,  525 
Probe,  uterine,  manner  of  introduction  and 
use  of,  108 
varieties  of  the,  96 
Proctorrhaphy,  503 
Prognosis,  124 

Puberty,  vaginal  examinations  before,  2 
Puerperal  state,  operations  during,  6 

Rectocei,e,  caused  by  perineal  laceration, 
483 
Emmet's  new  operation  for  lacerated 
perineum  and,  505 


Rectocele,  operations  for,  512 
details  of,  514 
pessaries  for,  387 
Recto-vaginal  touch,  examination  by,  55 
Rectal  touch,  examination  by,  54 
Rectum,  digital  eversion  of,  62 

examination  by  introduction  of  whole 

hand  into,  56 
examination  of  the,  with  the  specu- 
lum, 115 
Reflectors  for  specular  examination,  123 

Sarcoma,  diffuse,  of  the  uterine  mucosa, 

312 
Scarificator,  Butties',  S25 
Secretions,  vaginal,  inspection  of,  34 
Scirrhous  cancer,  diagnosis  of,  by  sponge- 
tent,  289 
Shield,  Sims',  for  wire  sutures,  425 
Sims'  position,  advantages  of,  25 
Sims'  speculum,  82 

methods  of  introducing  and  holding, 

85 

Single  women,  vaginal  examinations  of,  2 

Sound,    uterine,    counter-indications    and 

dangers  of  the,  101 

gentleness  and  dexterity  necessary  in 

the  use  of  the,  98 
indications  and  precautions  for  the  use 

of  the,  97 
information  obtained   by  the   use  of 

the,  100 
introduction  where   there    is  uterine 

displacement,  106 
manner  of  introducing  the,  103 
obstacles  to  the  passage  of  the,  1 07 
perforation  of  uterus  by  the,  99,  103 
varieties  of,  95 
Specula,  bi-  and  trivalve,  78 
cervical,  243 
cylindrical,  73 

advantages   and   disadvantages   of, 

75 
manner   of    introduction   in   Sims' 

position,  78 
method  of  introduction,  75 
valvular,    advantages    and    disadvan- 
tages of,  80 
manner  of  introduction,  80 
■varieties  and  methods  of  use  of,  73 
Specular  examination,  difficulties  in  mak- 
ing, 91 
Speculum,  applications  to  vagina  and  cer- 
vix made  through  the,  158 
counter-indications  to  use  of  the,  72 
examination  of  the  rectum  with  the, 

115 
Munde's  combination  Sims'  and  Nott's, 

93 
Neugebauer's  double  crescent,  93 
Simon's  "gutter,"  94 
Sims',  adjuncts  needed   when  using, 
84 
advantages  of  the,  82 
method  of  using  without  assistance 
of  nurse,  89 


INDEX. 


549 


Speculum.  Sms',  methods  of  introducing 
and  holdin;,'',  85 
modifications  of,  83,  91 
use  in  knee  chest  position,  90 
Sponges,  method  of  cltant-iug,  07 
Sponge  tents  see  (Tents),  2G5> 
Sterility,    caused  by  constricted   external 
OS,  322 
dilatation  of  uterus  in,  286,  292 
due  to  cervical  laceration,  448 
due  to  displacement  of  uterus,  use  of 

pessaries  in,  353 
due  to  excessively  acid  vaginal  secre- 
tion, 152 
due  to  perineal  laceration,  484 
influence  of  trachelorrhaphy  on,  471, 

475 
intra-uterine    injection   of  semen    in 
249 
Studley's  modified  Sims'  speculum,  92 

l^robe-pointed  adjustable  knife,  291 
Styptic  applications,  173,  177,  232 

cotton,  177 
Subinvolution  due  to  lacerated  cervix,  432 

vaginal  tamponade  in,  211 
Suppositories,  191 
Sutures,  419 
catgut,  422 

materials  used  for,  431 
methods  of  threading  needle  for  wire, 

423 
precautions   necessary   to  success  in 

use  of,  419 
shield  used  in  twisting,  425 
silk,  method  of  rendering  aseptic,  421 
silver-vsrire,  422 
wire,  method  of  passing  and  twisting, 

425 
wire,  removal  of,  426 
wire-scissors  for  removing,  427 
wire-twister  for,  425 
Symptoms,  causation  of,  16 

estimation  of  the  value  of,  11 
Syringe,  applicator,  245 

aspirating,  Munde's,  121 

cervical  mucus,  221 

hypodermic,  for  diagnostic  aspiration, 

120 
vaginal,  138 

Tactus  Eruditus,  necessity  for  the,  2 
Tamponade,  intra-uterine,  241,  247 
Tamponade  of  the  vagina,  194 
in  pelvic  peritonitis,  211 
in  vaginismus  ;  in  stenosis  ;  as  a  me- 
chanical dilator,  213 
therapeutic  effects  of,  212 
through  speculum,  203 
Tampons,  vayiiud,  4 

as  an  absorbent,  217 
as  a  hemostatic,  213 
as   a    means   of   diagnosing  endome- 
tritis, 217 
as   a   mechanical   support   and    stim- 
ulus  to  the  pelvic  vessels,    and   as 
an  alterative  by  pressure,  210 


Tampons,  raginnl,  as  a  retaining  agent  for 
substances  introduced  into  the  ute- 
rus, 204 
as  a  substitute  for  a  pessary,  208 
as  a  support  to  uterus  or  ovary,  205 
auto-insertion  of,  210 
dry  medicated,  177,  200 
insertion  in  knee-chest  position,  207 
materials  used  in  construction  of,  197 
medicated,  introduction  of,  201 
medicated,  precautions  iu  the  use  of, 

201 
precautions  in  the  use  of,  197 
shapes  and  construction  of,  195 
time  and  manner  of  removal,  204 
use  in  prolapsus,  208 
uses  of,  194 
Tampon-tube,  202 
Temperament  as  affecting  feasibility   of 

oijeration,  0 
Tenacula,  84 
Tenaculum,  injuries  iuJJicted  on  the  cervix 

by  the,  114 
Tents,  compressed  cornstalk  pith,  284 
gentian  root,  284 
laminaria,  277 
constriction  by  internal  os,  279 
length  of  time  to  Ije  left  in  utero,  280 
manner  of  introduction,  279 
removal  of,  280 

Schultze's  method  of  using,  231 
special  indications  for  the  use  of,  289 
medicated,  249 

Sass'    counter-pressure    loop    for    re- 
moval of,  274 
slippery  elm  bark,  284 
sjwiKje,  counter-indications   and   dan- 
gers of,  276 
covered,  275 
curved,  271 

danger  of  septic  infection  from,  275 
diagnosis   of   scirrhous    cancer   by, 

289 
insertion  of,  anesthesia  during  the, 

274 
length  of  time  to  be  left  in  utero,  273 
manner  of  introduction  of,  271 
method  of  making,  269 
never  to  be  introduced  in  the  physi- 
cian's office,  275 
one  not  to  be  immediately  succeeded 

by  another,  275 
precautions  after  use  of,  274 
precautious  in  the  use  of,  277 
proper  size  to  use,  272 
removal  of,  273 
special  indications  for,  288 
ttipel/^  method  of  introducing,  283 
rapid  dilatation  of,  282 
special  advantages  of,  282 
special  indications  for,  289 
Trachelorrhaphy,  after-treatment,  468 
assistants  needed  for,  461 
counter-indications  to,  472 
danger  of  menstruation  immediately 
following,  474 


550 


INDEX. 


Trachelorrhaphy,  danger  of  pelvic  cellu- 
litis and  peritonitis  following,  475 
danger  of  primary  hemorrhage  in,  473 
danger  of  secondary  hemorrhage  after, 

4;4 
danger  of  sloughing  of  cervical  tissue 

after,  474 
danger  of  too  thorough  denudation  in, 

473 
details  of  operation,  462 
dystocia  from,  at  subsequent  labor,  477 
failure  of  lips  of  wound  to  unite  in,  475 
indications  for,  456 
influence  of,  on  sterility,  471,  476 
instruments  used  for,  459 
introduction  of  sutures  in,  464 
menstruation   before   removal  of  su- 
tures in,  470 
needles  us^ed  for,  460 
j>ossible  dangers  of,  473 
possible  evil  results  after,  475 
possible    modifications    of    operative 

details  in.  466 
precautions  during,  468 
preparation  of  patient  for,  461 
proportion  of  failures  in,  476 
relaceration  at  subsequent  labor  after, 

477 
removal  of  sutures  after,  469 
results  achieved  by,  470 
without  anesthesia,  461 
Treatment  of  gynecological  cases,  general 

considerations  influencing  the,  1 
Tumors,  diagnostic  palpation  of,  39 
ovarian,  when  to  operate  on,  414 
pelvic,  aspiration  of,  117 
Tupelo  tents  (see  Tents),  282 

Ureter,  passage  of  sound  into  the,  71 
Urethra,  dilatation  of,  dangers  and  contra- 
indications in,  133 
indications  and  operation  for,  130 
instrumental  examination  of,  67 
Urethral  glands,  inflammation  of  the,  34 
Urethrocele  and  cystocele,  operation  for, 

Emmet's,  521 
Urethrocele,  definition,  523 
operation  for,  523 
symptoms  of,  523 
Uterine  cavity,  applications  to  the,  218,  226 
agents  most  used,  235 
by  applicator  syringe,  245 
by  injection,  247 

by  medicated  tents  or  bougies,  249 
cases  of  shock  after,  256 
choice  of  method,  253 
counter-indications  and  dangers  of,  255 
nitric  acid,  242,  257 
ointments,  252 
on  a  caustic-holder,  253 
on  applicators,  advantages  and  disad- 
vantages of,  243 
on   applicators,    through   the   dilated 

cervical  canal,  241 
on  applicators,  through  the  undilated 
cervical  canal,  237 


Uterine  cavity,  applications  to,  precautions, 
254 
therapeutic  value  of,  257 
Uterine    cavity,  conditions  necessary    for 
intra-uterine  medication,  236 
cure  ting  of  the,  308 
tamponade  of  the,  247 
therapeutic  agents  applied  to  the,  281 
Uterine  dilators,  Emmet's,  268 
expanding,  262 
expanding,  objections  to,  266 
metrotomes,  290 
Moles  worth's,  266 
rubber  tubes  and  bags,  266 
sounds,  259 
the  index-finger,  268 
Uterine  hemorrhage,  227 
Uterine  probe,  manner  of  introduction  and 
use  of,  108 
varieties  of  the,  96 
Uterine  repositor,  Emmet's,  340 
Uterine  sound  and  repositor,  Jennison's,  389 
Uterine   sound,     counter-indications    and 
dangers  of  the,  101 
gentleness  and  dexterity  necessary  in 

the  use  of  the,  98 
indications   and   precautions   for   the 

use  of  the,  97 
information  obtained  by   the   use  of 

the,  100 
introduction  of,  where  there  is  uterine 

displacement,  106 
manner  of  introducing  the,  103 
obstacles  to  the  passage  of  the,  107 
perforation  of  the  uterus  by  the,  99, 

103 
varieties  of  the,  95 
Uterus,  areolar  hyperplasia  of  the.  227 
diagnostic  curetting  of  the,  110 
defective  development  of  the,  229 
dilatation  of,  amount  and  rapidity  of 
dilatation,  264 
anesthesia  in,  265 
by  expanding  dilators,  262 
gradual,  269 

by  graduated  sounds,  259 
by  rubber  tubes  or  bags,  266 
by  tents,  269 

conditions  necessary  in,  258 
counter- indications  and  dangers  in, 

289 
for  purposes  of  diagnosis,  108 
frequency  of,  265 
Fritsch's  method,  261 
indications  for,  285 
in  dj'smenorrhea,  287 
pain  during,  265 
rapid,  258 

Schultze's  method,  281 
special  advantages  of  various  agents, 

289 
special  indications  for  each  method, 

285 
with  cutting  instruments,  290 
with    cutting  instruments,    indica- 
tions, 291 


INDEX. 


551 


Uterus,  dilatation  of,  without  cutting  in- 
struments, 2o8 
displaced^  aato-reposition  of,  in  knee- 
chest  position,  3o8 
reposition  of,  by  gravitation  and  at- 
mospheric pressure,  Jj-JS 
reposition  of,  by  instruments,  338 
reposition  of  the,  by  the  fingers,  330 
reposition  of,  in  knee-chest  position, 
330 
dis2)lace)nents  of,  diagnosis  of,  by  vagi- 
nal touch,  46 
lateral,  pessaries  for,  386 
pessaries  for  ante-,  371 
l^osition  of  cervix  in,  51 
probability  of  cure  by  a  pessary,  370 
retro-,  pessaries  for,  377 
vaginal  tamponade  in,  205,  211 
exainiiintion   of  the,  with  sound   and 

probe,  95 
inspection   and  indagation  of  the  di- 
lated, 108 
inverted,  dangers  of  rapid  replacement 
of  the,  344 
gradual  replacement  of  the,  345 
replacement  of  the,  methods,  342 
spontaneous  reduction  of  the,  346 
time  required   for  replacement    of 
the,  344 
local  depletion  of  the,  amount  of  blood 
to  be  taken,  322 
application  of  leeches  for,  323 
counter-indications  and  dangers  of, 

323 
in  amenorrhea  from  hyperemia,  322 
indications  for,  321 
scarification,  325 
value  of,  in  acute  congestion,  321 
value  of,  in  chronic  congestion,  322 
malignant  disease  of  the,  228 
normal  position  of  the,  63 
prolapse  of,    artificial,  for   diagnostic 
purposes,  113 
hypertrophic  cervix  in,  amputation 

of,  by  galvano-cautery  loop,  530 
hypertrophic  elongation  of  the  cer- 
vix simulating,  527 
hypertrophic    elongation  of    intra- 
vaginal  portion  of  cervix  simulat- 
ing,  528  ' 
operation   for,  accidents    following 

the,  534 
operation  for,  Bischoff 's,  532 
operation  for,  Fritsch's,  532 
operation  for,  Hegar's,  532 
operation  for,    indications  for  the, 

528 
operation  for,  Lefort's,  533 
operation  for,  Martin's,  532 
operation   for,    modified    Stoltz-Si- 

mon,  530 
operation  for,  Neugebauer's,  533 
operation  for,  objects  of  the,  529 
operation  for,  permanency  of  results 

in,  535 
operations  for,  530 


Uterus,  prolapse  of.  pessaries  for,  387 
symptoms  and  significance,  528 
varieties  and  degrees,  525 
with  one  or  both  walls  of  the  vagina, 
525 

retroverted  and  adherent,  replacement 
of  the,  341 

retro-displaced,  manual  repositicn  of 
the,  331 

sloughing   of  whole,  after  curetting, 
320 

subinvolution  of  the,  227 

Vagina,  application  of  medicinal  agents  to : 

alteratives,  173 

astringents,  173 

by  injection,  137 

by  insutti  ition,  193 

caustics,  173 

emoUieuts,  173 

fluids,  168 

hydragogues.  173 

narcotics,  173 

ointments,  188 

styptics,  173 

suppositories,  191 

through  specula,  158 
Vagina,  diagnostic  aspiration  through,  120 

injection  of  medicinal  substances  into 
the  tissue  of  the,  327 

retention  of  air  in,  in  perineal  lacera- 
tion, 483 

tamponade  of  the,  194 
Vaginal  dei^ressor,  Sims',  84 
Vaginal  examination  before  puberty,  con- 
ditions requiring,  2 
Vaginal  examination,  digital,  41 

digital,  in  dorsal  position,  44 

during  menstruation,  3 

in  advanced  age,  8 

in  j'ouiig  single  women,  conditions  re- 
quiring, 2 

rupture  of  hymen  during,  3,  43 

with  speculum,  72 
Vaginal  fornix,  examination  of  the,  51 
Vaginal  injections.  137 

after  coitus,  153 

alterative,  151 

amount  of  fluid  to  be  used,  143 

astringent,  149 

cleansing,  153 

composition  of,  147 

counter-indications  and  dangers,  157 

disinfectant,  148 

emollient,  152 

hot,  145 

hot,  in  pelvic  congestion,  155 

indications  and  utility  of,  152 

manner  of  using,  141 

sedative,  152 
Vaginal  irrigation  during  plastic  operatioiiS 

on  the  genitals,  157 
Vaginal  poultice,  162,  200 

sachets,  200 

secretions,  inspection  of,  34 

supporters,  350 


OO! 


INDEX. 


Vaginal  suppositories,  191 
syringes,  138 
syringes,  danger  of  using  tube  with 

central  terminal  perforation,  147 
syringes,  proper  form  of  vaginal  tube, 

14G. 
wall,  prolapse  of  anterior,  operations 

for,  519 
wall,  prolapse  of  posterior,  operations 

for,  512 
walls,   subinvolution    of,  in    perineal 

laceration,  483 


Vaginismus,  vaginal  tamponade  in,  313 
Vaginitis,  treatment  of,  174 
Vagino-abdominal  supporters,  389 
Vaseline,  189 

Vegetations,  intra-uterine,  228 
Verbal  examination  of  patient,  10 
Vesical  touch,  examination  by,  56 
Vesicorectal  touch,  uses  of,  57 
Virginity,  intact  hymen  as  proof  of,  48 

Wire -TWISTER,  425 


Date  Due 

i 

1 
1 
1 



f)J 

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'-V-'^^-^i  '■'  -« 


